S2332 Complete Occlusion of the Common Bile Duct Due to Erosion of a Gastroduodenal Artery Coil

Abstract

INTRODUCTION: Endoscopic intervention remains the first-line method for treating upper gastrointestinal bleeding. In the case of bleeding duodenal ulcers and failed endoscopic hemostasis, visceral artery embolization has become standard of care at many centers because of its high efficacy and minimal side-effect profile. We present a patient who presented with ascending cholangitis due to complete occlusion of the CBD after migration of a gastroduodenal (GDA) coil. CASE DESCRIPTION/METHODS: 53-year-old male with history of duodenal ulceration and massive hemorrhage status post graham patch repair and suture ligation of the GDA followed by elective embolization of the GDA, complicated by disruption of the common bile duct (CBD) and hepatic artery hemorrhage status post stenting, presented 30 months after GDA embolization with transaminitis and recent hospitalization with Klebsiella bacteremia of unclear etiology. Subsequent outpatient ERCP revealed complete obstruction of the CBD at the level of the GDA coils. Manipulation of wires allowed for passage through a fistula that ended on the bulb side of the pylorus. Cholangioscopy revealed erosion of nearly the entire GDA coil into the bile duct entrapping multiple portions of the biliary wall. Various sites were probed with wire but without ability to pass. Patient was referred for percutaneous biliary tube placement and initial plan was to repeat ERCP after PTC to try to pull coils out of the duct with forceps. However, subsequent cholangiogram and intervention resulted in successful recanalization of distal CBD obstruction and placement of internal/external biliary drain. Intraluminal portion of the coil pack had migrated into the duodenum and was removed. A 10 mm × 60 mm covered stent was positioned under fluoroscopic guidance to reconnect the ducts. DISCUSSION: Percutaneous endovascular embolization is generally safe and capable of achieving hemostasis in 93% of emergent cases of GI bleeding nonamenable to endoscopic therapy. Coil migration causing biliary obstruction, although rare, has been previously reported including a few case reports involving the embolization of the hepatic arteries and one case in the English literature involving the GDA. ERCP with removal of the coils is the best management. When ERCP fails, as in our case, decompression of the biliary system by PTC or surgery should be considered.Figure 1.: ERCP showing GDA coils in the CBD.Figure 2.: ERCP cholangiogram showing complete obstruction of the CBD.Figure 3.: IR Cholangiogram showing recanalization of CBD.