An Unexpected Outcome After Coil Embolization for Recurrent Upper Gastrointestinal Bleed

Abstract

Non-variceal bleeding can have significant morbidity and mortality if not adequately controlled. Endoscopy is the first-line treatment, but 5% to 10% of the time these bleeds require alternate intervention. The role of early elective surgery or angiographic embolization in selected high-risk patients to prevent rebleeding remains controversial. Even after embolization, complications and further bleeding can occur. We report a case of coil migration leading to recurrent bleeding requiring surgical intervention. 45-year-old male with a past medical history of perforated duodenal ulcer post laparoscopic repair with a Graham patch secondary to NSAID and alcohol use presented to Akron City Hospital for hematemesis. Initial EGD showed a large cratered duodenal ulcer with a visible vessel in the duodenal bulb. The visible vessel was spurting blood and therefore epinephrine was injected in four quadrants followed by bipolar gold probe therapy, but the bleeding resolved only after two hemoclips were placed. The bleeding returned and interventional radiology performed a coil embolization of the gastroduodenal artery. About two weeks later, he presented back to the ER with hematemesis and melena with a hemoglobin of 5.9 g/dL [14-18 g/dL]. Repeat EGD showed a large duodenal ulcer with adherent clot and previously placed embolization coil erupting through the mucosa from a branch of the gastroduodenal artery. Bleeding continued from this site as noted by dark red blood from a nasogastric tube and decreasing hemoglobin despite multiple blood transfusions. General surgery was consulted and the concern was that the coil migration was allowing continued bleeding, so they performed a laproscopic vagotomy, antrectomy, with billroth 2 reconstruction. Complication with CBD injury occurred requiring extra surgical intervention. Bleeding finally was controlled with the completion of this surgery. Embolization of the gastroduodenal artery is a safe and effective technique for a bleeding duodenal ulcer however it is important to remember complications occur. The endoscopic view of arterial embolization coils is a rare but known complication. In our case, the migrated coil provided a nidus for continued UGIB and required a complicated surgery to correct. The prognostic value of viewing an embolization coil with regard to re-bleeding incidence remains unclear. Close follow up is needed as re-bleeding can occur warranting further therapies and even surgical interventions.