Percutaneous gastrostomy is a widely performed pro- cedure in patients who require enteral nutrition or gas- tric decompression. Minimally invasive techniques, such as percutaneous endoscopic gastrostomy (PEG) or percutaneous radiologic gastrostomy (PRG) have largely replaced surgical gastrostomy in clinical practice (1).
Several studies have been undertaken to evaluate the success and safety of percutaneous gastrostomy (2, 3).
Major complications have been reported to range from 0 to 6% and minor complications from 2.9-15% (2-4).
There have been few reports of gastric ulcer bleeding related to indwelling gastrostomy tubes (5-7). In previ- ous cases, ulcer bleeding was controlled by endoscopic local injection with epinephrine. However, to our knowledge, no studies have reported on massive gastric ulcer bleeding related to a gastrostomy tube that re- quired transcatheter arterial embolization to stop the gastric ulcer bleeding. We present a case of massive gas- tric ulcer bleeding caused by a balloon replacement tube
that required transcatheter arterial embolization to stop the gastric ulcer bleeding.
Case Report
A 77-year-old woman was referred to interventional radiology for embolization of acute gastrointestinal re- bleeding. Two days previously, she had experienced a first episode of acute gastrointestinal bleeding, and had received local injection with a solution of epinephrine in sodium chloride into the bleeding gastric ulcer by an en- doscopic approach.
The patient had a history of a cerebrovascular acci- dent 10 years previously. Initial PEG had been per- formed for nutritional support three years previously at another hospital using a 20-F mushroom type tube, which was changed three times over a short time period with identical tube types.
Twenty days before her acute bleeding episode, a gas- trostomy feeding tube was replaced by endoscopic ap- proach with a 24-F balloon replacement tube (WILSON- COOK, Winston-Salem, NC., U.S.A.) due to previous tube dislodgement. At this time, an upper endoscopy re- vealed no gastric ulcer.
The patient subsequently underwent an upper en- doscopy; acute bleeding due to a gastric ulcer was ob- served at the posterior wall of the gastric angle. The gas-
J Korean Radiol Soc 2007;56:137-139
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Transarterial Embolization of Massive Gastric Ulcer Bleeding in Gastrostomy Patients Caused by a Balloon
Replacement Tube: A Case Report1
Byong Jong Youn, M.D., Jin Hur, M.D., Kwang-Hun Lee, M.D., Jong Yun Won, M.D.
1Department of Diagnostic Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
Received August 18, 2006 ; Accepted October 27, 2006
Address reprint requests to : Jin Hur, M.D., Department of Diagnostic Radiology, Yonsei University College of Medicine, Yongdong Severance Hospital, 146-92, Dogok-dong, Kangnam-gu, Seoul 135-270, Republic of Korea
Tel. 82-2-2019-3510 Fax. 82-2-3462-5472 E-mail: [email protected]
We present the case of a 77-year-old woman with massive gastric ulcer bleeding caused by a balloon replacement tube that required emergent transcatheter left gastric arterial embolization to stop the ulcer bleeding.
Index words :Gastrostomy Stomach, ulcer Embolization
trostomy tube was placed at the anterior wall of the low- er body opposite the gastric ulcer; the tip of the balloon replacement tube was near the gastric ulcer (Fig. 1A).
Endoscopic local injection with a solution of epineph- rine in sodium chloride was performed to stop the ulcer bleeding. Two days later, the patient had a second episode of massive bleeding. Laboratory testing showed the following: 7.1 g/dL hemoglobin, 5.4 mg/dL total bilirubin, 2.8 g/dL albumin and a 13.1 sec prothrombin time. The blood pressure was 90/60 mmHg, and six units of whole blood were transfused.
Emergent left gastric arteriography was performed, and showed active contrast media extravasation with a pseudoaneurysm at the posterior branch of the left gas- tric artery (Fig. 1B). Transcatheter arterial embolization was performed using a 3-F coaxial microcatheter (Renegade; Medi-Tech/Boston Scientific, Natik, MA., U.S.A.) using histoacryl (histoacryl 0.5 mL and iodized oil 1 mL mixture) to stop the gastric ulcer bleeding (Fig.
1C); this procedure was successful and the bleeding stopped. However, the patient deteriorated due to multi- organ failure. Ten days after the embolization, she died of respiratory and hepatic failure.
Discussion
Gastrostomy feeding is a well-tolerated and efficient method of providing enteral nutrition in patients who cannot tolerate oral feeding. The methods used for such alimentation have been associated with minimal stress, morbidity, and mortality, and have acceptable long- term patient outcome.
Many studies have demonstrated the safety and effica- cy of percutaneous gastrostomy (1-4). Wollman et al.
(2) performed a comparative meta-analysis of PRG, PEG, and surgical gastrostomy and concluded that PRG had the highest success rate and the lowest complication rate. However, the long-term success of this tube has
Byong Jong Youn, et al : Transarterial Embolization of Massive Gastric Ulcer Bleeding in Gastrostomy Patients Caused by a Balloon Replacement Tube
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A B
Fig. 1. A 77-year-old woman presented with acute gastrointestinal bleeding.
A. Upper endoscopy revealed a bleeding gastric ulcer at the poste- rior wall of the gastric angle (black arrows). A balloon replacement tube was placed at the anterior wall of the lower body opposite the gastric ulcer. The tip of the balloon replacement tube is in close proximity with the gastric ulcer (white arrow).
B. Left gastric arterial angiography showing contrast media ex- travasation with pseudoaneurysm at the posterior branch of the left gastric artery (long arrows). Note the overlapped digital sub- traction artifact of the endogastric balloon (short arrows) and the balloon replacement tube with extravasated contrast media.
C. Transcatheter arterial embolization was performed using a 3- coaxial microcatheter with histoacryl (histoacryl 0.5 mL and iodized oil 1 mL mixture); gastric bleeding then stopped.
C
been limited by problems with catheter obstruction and dislodgement; this may be related to the gastrostomy tube conformation.
Reports of a gastric ulcer development after balloon gastrostomy tube placement are scarce (5-7).
Explanations have been published regarding the mecha- nism underlying the development of gastric ulcer after balloon gastrostomy tube placement. Kanie et al. (8) re- ported that a PEG tube with a long protruding tip was associated with a significantly higher frequency of post- PEG gastric ulcer due to contact injury to the gastric mu- cosa caused by the tip of the tube. In our case, the gas- tric ulcer was observed on the posterior wall of the gas- tric angle, where the tip of the balloon tube came into contact with the mucosa. Moreover, the ulcer appeared in a previously stable patient shortly after the initial gas- tric tube was replaced by a balloon replacement tube.
This outcome suggests that the development of a gastric ulcer, after balloon gastrostomy tube replacement, may be due to mechanical injury caused by the tip of the tube to the gastric mucosa.
Delatore et al. (5) reported two cases of gastric ulcer bleeding following balloon gastrostomy tube replace- ment; in these cases, the ulcer was located at the site where the tip of the tube was wedged against the poste- rior gastric wall. The ulcer was treated by local injection with a solution of epinephrine in sodium chloride which was sufficient to stop the ulcer bleeding. However, in our case, endoscopic local injection was insufficient to stop the gastric ulcer bleeding; emergent left gastric arte- rial embolization was required to treat the bleeding.
The time interval between gastrostomy placement and the development of gastric ulcer is uncertain. In several case reports, gastric ulcer bleeding occurred two weeks to six months following gastrostomy tube placement (5,
7). However, there is one case report where gastric ulcer bleeding occurred 12 years after gastrostomy tube place- ment (6). In our case, gastric ulcer bleeding occurred three weeks after the balloon tube replacement.
The case reported here demonstrates that balloon re- placement tube placement can cause massive gastric ul- cer bleeding; in this case, transarterial embolization was needed to stop the ulcer bleeding. Therefore, choosing the appropriate tube type may be crucial for preventing gastric ulcer bleeding after gastrostomy tube replace- ment.
References
1. Wills JS, Oglesby JT. Percutaneous gastrostomy. Radiology 1983;
149:449-453
2. Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale A.
Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology 1995;197:
699-704
3. Wollman B, D’Agostino HB. Percutaneous radiologic and endo- scopic gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol 1997;169:1551-1553
4. Dinkel HP, Beer KT, Zba¨ren P, Triller J. Establishing radiological percutaneous gastrostomy with balloon-retained tubes as an alter- native to endoscopic and surgical gastrostomy in patients with tu- mors of the head and neck or esophagus. Br J Radiol 2002;75:371- 377
5. Delatore J, Boylan JJ. Bleeding gastric ulcer: a complication from gastrostomy tube replacement. Gastrointest Endosc 2000;51:482- 484
6. Weiss B, Fradkin A, Ben-Akun M, Avigad I, Ben-Shlush A, Jonas A. Upper gastrointestinal bleeding due to gastric ulcers in children with gastrostomy tubes. J Clin Gastroenterol 1999;29:48-50 7. Spiegelman G, Goldberg RI. Gastric ulceration following PEG re-
placement. Gastrointest Endosc 1992;38:397-398
8. Kanie J, Akatsu H, Suzuki Y, Shimokata H, Iguchi A. Mechanism of the development of gastric ulcer after percutaneous endoscopic gastrostomy. Endoscopy 2002;34:480-482
J Korean Radiol Soc 2007;56:137-139
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대한영상의학회지 2007;56:137-139
경피적위루술 시행환자의 풍선치환튜브에 의해 발생한 대량 위궤양출혈1
1영동세브란스병원 영상의학과
윤병종・허 진・이광훈・원종윤
저자들은 경피적 위루설치술을 시행 받은 77세 여자환자에서 위장벽 내에 존치된 풍선치환튜브에 의해서 발생한 대량위궤양출혈로 인해 응급좌위동맥색전술을 시행하였던 증례를 보고하고자 한다.
