1884 Migration of Embolization Coil in a Crohn’s Patient With NSAID-Induced Peptic Ulcer Disease

Abstract

INTRODUCTION: Peptic ulcer-related bleeding has a high mortality rate if not controlled. If endoscopic interventions fail, interventional radiology or surgical intervention is often considered. We report a case of rare complication of Transcatheter Arterial Embolization (TAE) for bleeding duodenal ulcer in a patient with Crohn’s Disease. CASE DESCRIPTION/METHODS: A 69-year-old female with a previous medical history of Crohn's colitis (on prednisone taper for active Crohn’s disease/pending initiation of biologic therapy) presented to the emergency department for generalized weakness, nausea, non-bloody, non-bilious emesis and melena. No prior history of gastrointestinal bleeding, antiplatelet or anticoagulation use was reported. Medications includes: Prednisone 20mg and Naproxen 400mg (BID or TID). Hemoglobin was 6.0 (11.0-16.2 g/dL), BUN 46 (8-26mg/dL), Cr 1.54 (0.44 – 1.00 mg/dL). Upper GI bleed was suspected with the initiation of Pantoprazole 80mg IV, 3 units of pRBC and Intravenous fluids. Endoscopy performed post-resuscitation revealed LA Grade D esophagitis, large non-bleeding duodenal bulb ulcer with extension into the sweep. No endoscopic therapy was performed. Twenty hours later, the patient became hemodynamically unstable requiring massive transfusion. As ulcer was not amenable to endoscopic therapy, Interventional radiology was consulted who TAE with the placement of two coils in the gastroduodenal artery (GDA). The patient tolerated the procedure well without any recurrence of bleeding. A follow-up endoscopy four weeks later, showed improvement in ulceration with only a 3-4 mm area of non-bleeding, healing ulcer with a coil protruding from ulcer site. The coil was left in place without any manipulation to the area. The patient was advised to discontinue NSAIDs and continue Pantoprazole 40 mg BID. In the interim, the patient was started on Vedolizumab (Entyvio) with improvement in CRP and abdominal pain. DISCUSSION: Embolization of GDA is safe and effective in patients with high surgical risk. Complications such as duodenal ischemia, hepatic artery embolization, duodenal stenosis do exist. Migration/Erosion of coil into lumen can occur, especially in a patient with active Crohn’s disease. Ulceration surrounding the coil can occur with a consequence of bleeding, which would require surgical intervention if endoscopic hemostasis is unable to be achieved.