S2164 A Rare Case of Coil Migration After Arterial Embolization of the Gastroduodenal Artery for Gastrointestinal Hemorrhage

Abstract

INTRODUCTION: Peptic ulcer disease is one of the most common causes of acute gastrointestinal hemorrhage. Treatment with endoscopic hemostasis is first-line. If this is unsuccessful, transcatheter arterial embolization (TAE) or a surgical approach is considered. The goal of TAE is to achieve hemostasis by selectively blocking the blood supply of the bleeding vessel while maintaining adequate collateral perfusion to the region. Complications associated with TAE include arterial dissection and post embolization organ ischemia. CASE DESCRIPTION/METHODS: A 71-year-old male presented to the hospital with acute onset hematochezia and hypotensive shock. Past medical history was significant for gastro-esophageal reflux disease, NSAID use, Hepatitis C, and polysubstance use. Patient described mild abdominal discomfort without nausea, vomiting, or hematemesis. Physical exam was notable for diffuse mild abdominal tenderness to palpation in all four quadrants. Laboratory studies showed hemoglobin 6.4 g/dL. Hemoglobin three days prior was 11.4 g/dL. Esophagogastroduodenoscopy (EGD) performed after hemodynamic resuscitation, revealed one large cratered duodenal ulcer with adherent clot (Forrest Class IIb) in the duodenal bulb. Epinephrine injection and cauterization with bipolar probe were performed with incomplete hemostasis. Further evaluation with mesenteric angiogram revealed extravasation in the small branch of the gastroduodenal artery (GDA). Embolization with coil placement of the GDA was performed by interventional radiology. Follow-up EGD in 2 days, showed one minimally oozing cratered duodenal ulcer with a non-bleeding, visible vessel (Forrest Class IIa) in the duodenal bulb. A coil was visualized protruding from the ulcer. The coil was not removed and no additional intervention was performed during endoscopy with spontaneous resolution of oozing. The patient responded well to the conservative management, and had an uneventful recovery. No more bleeding episodes or complication from coil migration noted over next few months. DISCUSSION: This case presents a unique scenario in which the embolization coil penetrated through the duodenal ulcer within 2 days of placement. In a single center study, the incidence of coil migration was found to be 3%. If no active bleeding or complication of migration noted at the time of discovery, then conservative management with close follow-up is favored after an interdisciplinary discussion between interventional radiology and gastroenterology.Figure 1.: Image 1. Visualization of embolization coil penetrating through the duodenal ulcer.Figure 2.: Image 2. Visualization of embolization coil penetrating through the duodenal ulcer.Figure 3.: Image 3. Visualization of embolization coil penetrating through the duodenal ulcer.