S2231 Successful Endoscopic Therapy of Acute Lower GI Bleeding From Serosal Vessel Within a Contained Perforation Abscess Cavity

Abstract

INTRODUCTION: We present a case of successful colonoscopic therapy of bleeding from a serosal vessel within a contained perforation cavity. CASE DESCRIPTION/METHODS: A 66 year old woman developed severe necrotizing post ERCP pancreatitis with walled off necrosis, multiple abdominal abscesses, and duodenal and colon perforation. She was transferred for evaluation of recurrent lower gastrointestinal bleeding which had been managed with transfusions due to her severe comorbidities. CT showed multiple abdominal collections with the dominant peripancreatic collection communicating with the descending colon. Colonoscopy showed large amount of blood clots and ischemic looking ulcers from 30-35cm from the anus. The scope could not be passed beyond 35cm due to stricture. A cavity was seen at 30cm which corresponded to the perforation from the peripancreatic collection seen on CT. This was filled with large amount of clots. The patient was managed conservatively and discharged back to the nursing facility. She was transferred back 6 weeks later with worsening bleeding. Repeat CT showed worsening abdominal abscesses and a drainage catheter was placed in to the loculated collection near the descending colon. CT angiogram showed bleeding from the stomach. Endoscopy was unremarkable. Sigmoidoscopy showed the known cavity at 30cm which was filled with clots and red blood. The drainage catheter was seen within the cavity. Once blood was cleared a stigmata of recent hemorrhage was seen and obliterated with hemostatic forceps. The bleeding stopped and patient was discharged back to the nursing home. DISCUSSION: Our patient presented with lower gastrointestinal bleeding from a non-gastrointestinal source since her bleeding occurred from a vessel outside of the colon. The blood drained through the colon through the perforation which is why she did not have significant bleeding nor fluid output through her drain since they drained preferentially through the large colonic fistula. Recognition of the stigmata of recent hemorrhage within the abscess cavity and hemostasis resolved the bleeding. It is safe to endoscope cavities communicating with the gut, especially when they are chronic and also have external drainage as in our patient since any CO2 insufflation or irrigation would drain outside of the body. Therefore such cavities including peripancreatic walled off necrosis, abscess, or contained perforation could be evaluated for cause of bleeding which can be safely treated using conventional hemostasis.Figure 1.: Blood clots (triangle) filling the perforated abscess is seen on the left and colon lumen (arrow) on the right.Figure 2.: Stigmata of recent hemorrhage (arrow) seen after clots cleared.Figure 3.: Percutaneous drain (triangle) is seen on the left and obliterated stigmata (arrow) on the bottom.