2386 Shock Liver: A Complication of Gastroduodenal Artery Embolization

Abstract

INTRODUCTION: PUD is the most common cause of acute upper GI bleeding. Duodenal ulcers are 4x more likely to bleed than gastric ulcers. Posterior duodenal ulcers, are more likely to erode into the gastroduodenal artery (GDA) resulting in massive bleeding requiring intervention. Liver failure is a known complication of gastroduodenal artery embolization due to inadvertent embolization of the main hepatic artery [1,2]. CASE DESCRIPTION/METHODS: A 71 year old lady presented with a hemoglobin of 5.7 g/dL with a baseline of 10.7 g/dL. She was resuscitated with pRBCs and fluids to a hemoglobin of 8.7 g/dL. EGD showed an active 3 cm bleeding ulcer at the duodenal bulb with a visible vessel and adherent clot. Hemostasis was achieved with epinephrine, two hemoclips and gold probe cautery. On POD# 5, she had two melenic stools and an acute drop in hemoglobin reaching a nadir of 6.4 g/dL which prompted a repeat EGD. An ulcerated area on the posterior wall of the bulb was bleeding, hemostasis with epinephrine and three hemoclip deployment failed. Subsequently, she underwent gastroduodenal artery coiling. During the embolization, the coil was partially protruding into the hepatic artery. Coil repositioning failed. POD# 1, AST and ALT trended up to 2814 IU/L and 1375 IU/L from a baseline of 14 IU/L and 10 IU/L on admission, respectively. INR trended up from 1.23 to 1.8, she developed encephalopathy, was diagnosed with shock liver and transferred to outside liver transplant center. DISCUSSION: Technical success rates of transcatheter arterial embolization are extremely high (>90%) while clinical success rates vary from 60%-90% [3]. This difference may be attributed to multiorgan failure, coagulopathy, and bleeding from trauma or invasive procedures [4]. A lack of understanding of the factors that influence clinical outcome also plays a role. Transcatheter therapeutic embolization has a very high rate of success and should be considered as an alternative to surgery in high-risk populations. [1,2]. Endoscopic embolization usually has a low rate of complications of rebleeding, infarction, and rarely coil migration [3,5,]. Coil migration has been described after embolization of the GDA, but infrequently been reported to be fatal. Our patient had movement of the sheath used to protect the hepatic artery and the catheter resulting in partial migration of the coils into the hepatic artery which led to shock liver. To our knowledge, few cases of coil migration inducing hepatic failure have been reported in the literature.