S2198 Are Migrated Variceal Coils Amenable to Endoscopic Treatment?

Abstract

Introduction: Embolization coil migration into the gastrointestinal tract is an extremely rare complication. Several case reports have described coil migration into the gastrointestinal tract after treatment of gastric varices, splenic artery pseudoaneurysm, and post-liver transplant. There is no standard of care for migrated coils, and treatment has ranged from conservative management to surgical/endoscopic removal. We report a rare case of coil migration into the stomach after direct intrahepatic portosystemic shunt (DIPS) and variceal coiling of gastric varices. Case Description/Methods: A 61-year-old man admitted with 3-week onset of epigastric pain. He has history of NASH cirrhosis complicated by bleeding esophageal and gastric varices status post coiling and embolization with DIPS in 2016. Pain was exacerbated by certain positions, and improved in the left lateral decubitus position. Pain was not related to food intake. Vitals were stable and labs were unremarkable at presentation.CT scan of abdomen and pelvis with IV contrast showed possible foreign body in the gastric lumen (Figure 1A). EGD showed migration of previous variceal coils into the gastric lumen, particularly around in the fundus and cardia (Figures 1B-C). Venogram was obtained to asses anatomy and coil location. This demonstrated complete occlusion of the previously embolized gastric varices. After the venogram, EGD was completed with successful removal of visibly migrated coils using small biopsy forceps (Figure 1D). No bleeding or complications occurred after the procedure. Although subsequent imaging showed remaining coils, there were significantly less compared to admission. The patient had intermittent resolution of his abdominal pain, but was readmitted several times afterwards for EGD removal of remaining coils. Discussion: Although etiology is unclear, the mechanism of variceal coil migration is likely related to fistula formation and inflammation within the gastric wall. In this case we attempted treatment endoscopically with removal of variceal coils with biopsy forceps. Successful removal of visualized coils alleviated abdominal pain, though it was temporary. An alternative treatment would be surgical intervention, however given risk of decompensation of cirrhosis and complications, it would be as a last resort. In the setting of successfully embolized vessels, we believe it is safe for endoscopic retrieval of the gastric coils in symptomatic patients.Figure 1.: (A) CT abdomen and pelvis showing metallic foreign body (red arrow) - coil migration from previous embolization. (B-D) Endoscopic images showing coils (yellow arrow) from previous IR intervention found in stomach fundus and cardia status post removal using small biopsy forceps.