Gastrointestinal Bleeding from a T-fastener

Abstract

Introduction: A gastrostomy tube provides nutritional access for individuals who do not have the ability to swallow or are at risk of aspiration. When gastrostomy tubes are placed by radiologists T-fasteners (TFas) are often used to perform gastropexy, a method of approximating the gastric and abdominal walls. Tfas can sometimes erode through the abdominal or gastric walls leading to GI bleeding. Case report: A 72 year old female with history of dysphagia and PEG tube feeding secondary to chronic inflammatory demyelinating polyneuropathy presented with melena. She underwent CT angiography and a bleeding vessel within a pseudoaneurysm in the abdominal wall was located. Embolization of the source vessel stopped the bleeding and she was discharged. She was readmitted after a week with recurrent melena and angiography again revealed the pseudoaneurysm with a bleeding vessel but this time failed to control bleeding with embolization. EGD revealed a large clot at the site of the internal balloon of the gastrostomy tube. The clot was dislodged revealing a bleeding vessel with Tfas (Figure 1). The wire attaching the two ends of the Tfas was running through the pseudoaneurysm and the visible vessel. On examination of the external abdominal wall the Tfas wires were not visible, as they had migrated within the abdominal wall. The PEG tube was pushed aside and the Tfas were mobilized using forceps. Using hot snare forceps the wire was cut and the Tfas were removed. Gold probe cautery was applied to treat the bleeding vessel and then the PEG tube was repositioned back to its original place (Figure 2). The patient subsequently had no further GI blood loss and was discharged.Figure 1Figure 2Discussion: The use of Tfas serves to assist in safe and appropriate placement of a gastrostomy tubes, but can lead to infections or fistula formation. Rarely bleeding due to Tfas can occur, and in our case the Tfas buried into a pseudoaneurysm within the gastric wall causing bleeding. Bleeding from gastrostomy sites is most commonly secondary to ostomy incision site related bleeding, but this case highlights the need to consider bleeding from buried Tfas within pseudoaneurysms that have exposed vessels within the gastric lumen. We report use of a hot snare forceps to cut the wire attaching the ends of the Tfas and then removing each of the metallic ends separately using a grasping forceps. The underlying vessel can then be ablated to prevent further blood loss.