A Coil Calamity

Abstract

Management of acute upper gastrointestinal bleeding (GIB) is standardized with initial approach focusing on resuscitation and endoscopic evaluation with therapeutic intent. In the event that a lesion is not amenable to endoscopic therapy, endovascular treatments have been successfully utilized, ranging from foam gel to selective vascular coil embolization. Endovascular therapy has been shown to be successful with several peri-procedural and long term adverse events. Here we describe a case of a 66-year-old female with past medical history of acute myeloid leukemia (AML) and recent allogenic stem cell transplant who presented with melena for one month and labs demonstrating profound anemia without evidence of hemorrhagic shock. She had a history of GIB previously treated with transcatheter arterial embolization (TAE) of the gastroduodenal artery (GDA) five years prior to this presentation. On current hospitalization, an EGD demonstrated several duodenal ulcers and three micro coils extruding from the base of the ulcer. No endoscopic interventions were attempted. Her melena persisted with ongoing anemia. An angiography failed to identify source of bleeding, but due to high surgical risk from comorbid conditions, a conservative approach was undertaken with acid suppression therapy and as needed blood transfusions. Her hemoglobin stabilized and the patient was successfully discharged. She has not experienced recurrence of bleeding at three months follow-up appointment. Coil migrations through the gastric and duodenal wall is a rare but possible complication of TAE that has previously been reported in the literature in up to 3% cases. More typical complications of TAE include occlusion of a nontarget vessel, vessel injury, local abscess, and allergic reaction to coils. Bleeding after coil migration may occur from weeks to several years after TAE as in our patient. Unlike the high risk stigmata of rebleeding that has been well described, the prognostic value of finding migrated coils on endoscopy has not been assessed in the literature for predicting likelihood of rebleeding. Due to the paucity of data, the approach to patient management should remain individualized, utilizing a multidisciplinary approach, including surgery, interventional radiology and gastroenterology.1951_A Figure 1. Duodenal Bulb/ sweep: Large ulcer1951_B Figure 2. Duodenal sweep: Coils protruding from ulcer base