CASE REPORT
A 44-year-old woman presented with hematemesis and melena. Laboratory evaluation showed a hemoglobin of 3.6 g/dL, down from 9.7 g/dL 1 month prior. An esophagogastroduodenoscopy revealed a large nonbleeding ulcer with a visible vessel in the duodenal bulb (Figure 1). Cauterization of the vessel was complicated by profuse bleeding and attempts to achieve hemostasis with epinephrine injection, electrocauterization, and clip placement failed. The patient subsequently underwent angiogram, which did not reveal any active extravasation. However, empiric coil embolization of gastroduodenal, inferior pancreaticoduodenal, and right gastroepiploic arteries was performed successfully (Figure 2). Repeat esophagogastroduodenoscopy 3 days later for continued melena showed the large duodenal ulcer with the embolization coils eroding through the ulcer bed into the duodenal lumen (Figure 3).
Figure 1.
Esophagogastroduodenoscopy revealing a large nonbleeding ulcer with a visible vessel in the duodenal bulb.
Figure 2.
Successful coil embolization of gastroduodenal, inferior pancreaticoduodenal, and right gastroepiploic arteries.
Figure 3.
Repeat esophagogastroduodenoscopy showing the large duodenal ulcer with the embolization coils eroding through the ulcer bed into the duodenal lumen.
The incidence of coil migration has been reported up to 3%.1 Coil migration may occur early after the embolization procedure if the base of the duodenal ulcer is eroding into the vessel or much later due to a local inflammatory response incited by the coil. No intervention is usually required for local migration due to the fibrosis around the migrated coil, although occasionally distant migration, ulceration, or rebleeding may occur.2–4 Distal migration of embolization coils is rare, and these patients are usually asymptomatic; hence, prophylactic removal of these coils is not advised. For symptomatic patients, given that no consensus has been established, each case should be individually addressed in a multidisciplinary fashion in collaboration with interventional radiology and surgery. Our patient was discharged 10 days after the initial presentation in stable condition. The patient remained stable on clinic visits at 2 weeks and 3 months after discharge with no evidence of gastrointestinal bleeding.
DISCLOSURES
Author contributions: AN Palagiri and S. Samo wrote the manuscript. All authors reviewed and approved the manuscript. S. Samo is the article guarantor.
Financial disclosures: None to report.
Informed consent was obtained for this case report.
REFERENCES
- 1.Leyon JJ, Littlehales T, Rangarajan B, et al. Endovascular embolization: Review of currently available embolization agents. Curr Probl Diagn Radiol. 2014;43:35–53. [DOI] [PubMed] [Google Scholar]
- 2.Jaurigue MM, Snyder M, Cannon M. Recurrent upper GI bleeding secondary to coil migration in a patient with known NSAID-induced peptic ulcer disease. Gastrointest Endosc. 2014;79:1004; discussion 1005. [DOI] [PubMed] [Google Scholar]
- 3.Dulskas A, Rudinskaite G, Maskelis R, et al. Duodenal ulceration following gastroduodenal artery embolization with coils. Endoscopy. 2015;47(suppl 1):E488–9. [DOI] [PubMed] [Google Scholar]
- 4.Hewgley WP, Webb DL, Garrett HE., Jr Migrated embolization coil causes intestinal obstruction. J Vasc Surg Cases Innov Tech. 2018;4:8–11. [DOI] [PMC free article] [PubMed] [Google Scholar]