Visible Coil After Embolization for a Bleeding Ulcer

Abstract

3 72-year-old woman was admitted for rectal bleeding. The patient was at 3 weeks after ventral hernia repair. After onsultation, a decision was made to perform a colonoscopy, hich revealed diverticulosis that was presumed to be the culprit t presentation. The service was reconsulted a few days later for ersistent decrease in hemoglobin. No rectal bleeding, melena, or ematemesis was noted. A decision was then made to perform an pper endoscopy. The exam noted a large duodenal ulcer (3 4 m) with overlying clot. A total of 23 mL of 1:10,000 epinephrine as injected around the ulcer base, and the clot was removed. A isible vessel was identified (Figure A), and an attempt at bipolar oagulation was done to ablate the vessel. Cessation of bleeding ailed, and active spurting was noted. An attempt to irrigate the esion for revisualization and repeat bipolar coagulation was unuccessful as a result of the large amount of blood within the orking field. Injection of an additional 20 mL of 1:10,000 epiephrine around the ulcer base succeeded in reducing the volume f active bleeding. An attempt at clot removal was unsuccessful. nterventional radiology was then consulted, and the patient unerwent emergency mesenteric angiography with coil embolizaion of the culprit vessels. A total of 14 coils (4 VORTX-18 iamond shape, 3.3 mm unrestrained coil length, Boston Scienific, Marlborough, MA; 12 Tornado coil, 5 mm proximal iameter, Cook, Bloomington, IN) were used to occlude the proxmal right gastroepiploic artery to the proximal gastroduodenal rtery. Bleeding was successfully attenuated. Five days after emboization, another episode of hematochezia was reported. An upper ndoscopy was repeated, and a clean based bulbar ulcer was idenified, with a visible coil extruding from the ablated vessel (Figures and C). No active bleeding was noted. A decision was made to epeat the colonoscopy; however, because of emerging complicaions from the recent hernia repair, the procedure was deferred. uring the next week, no further bleeding episodes were noted; he hemoglobin level remained stable, and follow-up as an outpaient was recommended. Peptic ulcer bleeding is a common medical emergency that esults in approximately 300,000 admissions per year in the United tates.1 The treatment of choice for upper gastrointestinal bleedng after adequate resuscitation is endoscopy with therapeutic ntervention. A combination of injection, thermal coagulation, and emostasis clips is typically used to effect therapy. For those who ave failed endoscopic therapy, emergent surgical intervention is he next step, which commonly entails a high operative mortality.2 oday, selective transcatheter arterial embolization (TAE) has been dded as an alternative modality or rescue therapy to surgery in he control of upper gastrointestinal hemorrhage. Originally inroduced in 1972 by Schenker et al,2 TAE has evolved into a highly elective, life-saving modality that complements the medical and urgical options in catastrophic, unrelenting bleeding. TAE inolves the selective catheterization of a desired vessel followed by ontrast injection. Occlusion of a culprit vessel is then mediated by aterials such as absorbable gel foam or steel coils, when contrast xtrusion is identified. Although not effective in all cases, studies have shown that hen successfully performed in high-risk patients (advanced age, leeding recurrence, multiple comorbidities), operative intervenion is avoided, and mortality is decreased by half.2 On the other and, studies have also shown no difference in clinical outcomes bleeding recurrence, death, need for further surgery) between urgical intervention and embolotherapy.3 The benefit, however, is ased on therapeutic success and the avoidance of any postopertive complications from surgery.