Upper GI Bleeding: A Case of the Wandering Coils

Abstract

Purpose: Introduction: In this case we ask: which came first, the migration or the perforation? Coil migration is a known complication of arterial embolization but is infrequently seen in the setting of a perforated gastric ulcer. This case represents the rare complications of PUD and arterial embolization where a gastric ulcer and pseudoaneurysm formed a fistulous tract exposing coils that were placed 1 week prior to the EGD. Case Report: A 63 year old male presented initially after being found down in a pool of blood. In the ED the patient was altered, hemodynamically unstable, and had 3 episodes of bright red blood per rectum. An EGD was done which showed a 3x4 cm ulceration in greater curvature of the stomach with some associated oozing but no visible vessel. Biopsies were taken but eventually returned negative. Due to concern for malignancy, a computed tomography of the abdomen was performed that day and this showed a large hematoma adjacent to the gastric wall measuring 7x 8 cm with a central pseudoaneurysm measuring 2 x 2.3 cm. IR was called and a celiac angiogram was performed which showed a large pseudoaneurysm off the distal splenic artery. Successful coil embolization was performed. After 2 days of observation the patient was discharged home, however, seven days later he presented again with hematochezia. Repeat EGD then showed the gastric ulcer base had perforated and there was protrusion of a coil-like material into the stomach. Due to these findings, surgery was notified. An emergent laparotomy revealed gastric ulceration with perforation and an unroofed splenic artery pseudoaneurysm with exposed coil. Some coils were also seen in the peritoneal cavity. A wedge resection of the gastric ulcer was performed and the splenic artery was ligated. The patient survived the second episode of GI bleeding and after a complicated hospitalization was eventually discharged home. Discussion: Coil migration of a splenic artery pseudoaneurysm has been described in case reports of pancreatic pseudocyst but is not a known complication in the setting of PUD. The EGD images are very impressive as they show exposed coil through the gastric wall. This patient's gastric ulcer caused an extra gastric hematoma to form and subsequently a splenic artery pseudoaneurysm. The ulcer perforated, forming a fistula into the pseudoaneurysm and exposing the coils. This case represents a rare complication of arterial coil embolization and PUD.