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Unexpected finding after gastroduodenal artery embolization
AT THE FOCAL POINT Massimo Raimondo, MD, Associate Editor for Focal Points
Unexpected finding after gastroduodenal artery embolization
An 87-year-old woman with melena and anemia was admitted to the hospital and underwent urgent GI endoscopy. During the procedure, a large clot adhering to the posterior wall of the duodenal bulb was identified. Its removal with a retrieval net revealed an underlying visible vessel with active oozing (A). After an ineffective attempt to obtain endoscopic hemostasis with epinephrine injection, argon plasma coagulation, and clips, interventional radiology was performed. Selective arteriography of the celiac trunk revealed no extravasation, so blind embolization of the gastroduodenal artery with 3 platinum coils (SPIRALES.01800 , coil B 3 mm, coil length 5 cm; Balt Extrusion, Montmorency, France) was carried out (B, continous arrow: coil; dashed arrow: clip). Hemostasis was achieved, and the patient’s subsequent clinical course was uneventful. Three months later, the patient returned to the hospital with epigastric pain and vomiting. Upper GI endoscopy revealed a foreign body (a metallic coil) protruding from the posterior wall of the duodenal bulb. The adjacent mucosa
www.giejournal.org
appeared inflamed and was friable on contact (C, D). Given the absence of active bleeding, no treatment was performed. Migration of transparietal coils after embolization of the gastroduodenal artery is rare. Because of the scarce number of cases currently documented, a standardized therapeutic protocol has not yet been established. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Riccardo Solimando, MD, Alessandro Pezzoli, MD, Viviana Cifalà, MD, Lucio Trevisani, MD, Paolo Pazzi, MD, Department of Gastroenterology, Azienda OspedalieroUniversitaria di Ferrara, Italy, Cona, Italy http://dx.doi.org/10.1016/j.gie.2017.02.017
Volume
-,
No.
-
: 2017 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Commentary Upper GI bleeding affects 100 out of 100,000 persons per year. It is a life-threatening condition, as demonstrated by a mortality rate as high as 10%. Historically, multiple efforts have been made to accomplish adequate hemostasis once hemodynamic stability is achieved. Since the 1960s, several techniques, ranging from epinephrine injection to argon plasma coagulation, have been described and are still in the hemostasis arsenal. Others like vasopressin infusion were deemed more useful in history books because of the high rates of rebleeding. In 1972, Rösch et al changed the fate of GI bleeding with the introduction of a novel approach: transarterial embolization (TAE). The first materials used were autologous clots and gelatin sponge, but they were soon dismissed because of the high rates of bowel infarction. Selective delivery thanks to better microcatheter systems allowed directed embolization, resulting in a lower risk of bowel infarction. Nowadays, embolization is achieved by the use of metallic coils, absorbable gelatin sponge, microspheres, and cyanoacrylate glue. Currently, the most widely used approaches to achieve bleeding control are medical and endoscopic therapies, which are successful in 95% of patients. When hemostasis cannot be achieved with these approaches, invasive procedures such as surgery are required. TAE is a noninvasive alternative that is useful for patients whose comorbidities contraindicate surgical interventions. Case series of patients undergoing TAE have reported clinical success rates ranging from 52% to 98%. Adverse events include groin hematoma, dissection of the target vessel, duodenal stenosis, bowel ischemia, and liver and spleen infarction. Coil migration is rare. It was reported in 4% of patients in a case series, and in all cases the coil moved from the gastroduodenal to the hepatic artery. The present case is one of the few describing transparietal coil migration. It might have been an effort of the duodenal wall to try to get rid of the foreign body. Although this foreign body is now causing symptoms, it is absolutely necessary for prevention of rebleeding in this patient, so leaving it in place seems like the most reasonable tactic. It would be interesting to check the outcome in this woman in the long-term follow-up. Gastroenterologists and endoscopists should be aware of the multiple strategies that can come in handy in dealing with a patient with uncontrolled GI bleeding, particularly of TAE. To minimize adverse events, TAE should always be performed in high-volume centers with experienced interventional radiologists. Lady Katherine Mejia Perez, MD Research Fellow Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2017
www.giejournal.org
Unexpected finding after gastroduodenal artery embolization
An 87-year-old woman with melena and anemia was admitted to the hospital and underwent urgent GI endoscopy. During the procedure, a large clot adhering to the posterior wall of the duodenal bulb was identified. Its removal with a retrieval net revealed an underlying visible vessel with active oozing (A). After an ineffective attempt to obtain endoscopic hemostasis with epinephrine injection, argon plasma coagulation, and clips, interventional radiology was performed. Selective arteriography of the celiac trunk revealed no extravasation, so blind embolization of the gastroduodenal artery with 3 platinum coils (SPIRALES.01800 , coil B 3 mm, coil length 5 cm; Balt Extrusion, Montmorency, France) was carried out (B, continous arrow: coil; dashed arrow: clip). Hemostasis was achieved, and the patient’s subsequent clinical course was uneventful. Three months later, the patient returned to the hospital with epigastric pain and vomiting. Upper GI endoscopy revealed a foreign body (a metallic coil) protruding from the posterior wall of the duodenal bulb. The adjacent mucosa
www.giejournal.org
appeared inflamed and was friable on contact (C, D). Given the absence of active bleeding, no treatment was performed. Migration of transparietal coils after embolization of the gastroduodenal artery is rare. Because of the scarce number of cases currently documented, a standardized therapeutic protocol has not yet been established. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Riccardo Solimando, MD, Alessandro Pezzoli, MD, Viviana Cifalà, MD, Lucio Trevisani, MD, Paolo Pazzi, MD, Department of Gastroenterology, Azienda OspedalieroUniversitaria di Ferrara, Italy, Cona, Italy http://dx.doi.org/10.1016/j.gie.2017.02.017
Volume
-,
No.
-
: 2017 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Commentary Upper GI bleeding affects 100 out of 100,000 persons per year. It is a life-threatening condition, as demonstrated by a mortality rate as high as 10%. Historically, multiple efforts have been made to accomplish adequate hemostasis once hemodynamic stability is achieved. Since the 1960s, several techniques, ranging from epinephrine injection to argon plasma coagulation, have been described and are still in the hemostasis arsenal. Others like vasopressin infusion were deemed more useful in history books because of the high rates of rebleeding. In 1972, Rösch et al changed the fate of GI bleeding with the introduction of a novel approach: transarterial embolization (TAE). The first materials used were autologous clots and gelatin sponge, but they were soon dismissed because of the high rates of bowel infarction. Selective delivery thanks to better microcatheter systems allowed directed embolization, resulting in a lower risk of bowel infarction. Nowadays, embolization is achieved by the use of metallic coils, absorbable gelatin sponge, microspheres, and cyanoacrylate glue. Currently, the most widely used approaches to achieve bleeding control are medical and endoscopic therapies, which are successful in 95% of patients. When hemostasis cannot be achieved with these approaches, invasive procedures such as surgery are required. TAE is a noninvasive alternative that is useful for patients whose comorbidities contraindicate surgical interventions. Case series of patients undergoing TAE have reported clinical success rates ranging from 52% to 98%. Adverse events include groin hematoma, dissection of the target vessel, duodenal stenosis, bowel ischemia, and liver and spleen infarction. Coil migration is rare. It was reported in 4% of patients in a case series, and in all cases the coil moved from the gastroduodenal to the hepatic artery. The present case is one of the few describing transparietal coil migration. It might have been an effort of the duodenal wall to try to get rid of the foreign body. Although this foreign body is now causing symptoms, it is absolutely necessary for prevention of rebleeding in this patient, so leaving it in place seems like the most reasonable tactic. It would be interesting to check the outcome in this woman in the long-term follow-up. Gastroenterologists and endoscopists should be aware of the multiple strategies that can come in handy in dealing with a patient with uncontrolled GI bleeding, particularly of TAE. To minimize adverse events, TAE should always be performed in high-volume centers with experienced interventional radiologists. Lady Katherine Mejia Perez, MD Research Fellow Mayo Clinic Florida Massimo Raimondo, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2017
www.giejournal.org