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abdominal ultrasound showed a hyperechoic focus in the right hepatic lobe corresponding to the findings on CT (Figure 1B). Ultimately, the patient was treated with two weeks of cefepime and metronidazole for her C. perfringens bacteremia with hepatic focus. Her clinical course improved with antimicrobial therapy. Hepatic function tests were within normal limits by the time of discharge. Discussion: C. perfringens causes cytotoxic infection due to its alpha toxin, a lecithinase which breaks down cell membranes leading to cell lysis. Thus, our patient's severe acute anemia is explained in part by hemolysis due to clostridial infection. This organism is an uncommon cause of gas-forming liver abscess. A prior review of 119 cases of patients with gas-forming pyogenic liver abscess found only 8 to be infected with clostridia species. Malignancy and immunosuppression are both risk factors for C. perfringens infection and septicemia, both of which are present in our patient and thus made her more susceptible to clostridial infection. The etiology of her infection was potentially a bacterial translocation from the gastrointestinal tract. Mortality rate in patients with sepsis due to C. perfringens has been previously estimated at 70-100%. Thus, prompt recognition of this clinical syndrome is paramount so that early treatment can be initiated. Early appropriate antimicrobial therapy was essential to this patient's good outcome.[3209] Figure 1. A) A CT scan of the abdomen showing a focus of gas in the right hepatic lobe (arrow). B) An ultrasound of the right upper quadrant showing focus of gas in the right hepatic lobe (arrow).

Introduction: Endoscopic cyst-gastrostomy and necrosectomy have been shown to be highly effective in the treatment of pancreatic walled of necrosis (WON). However, these procedures can be associated with significant complications including bleeding, infection, and perforation. Herein, we describe a case of upper GI bleeding secondary to erosion of a cyst-gastrostomy stent array into the splenic vasculature. Case Description/Methods: A 45-year-old male with a history of chronic pancreatitis presented to the emergency room with acute-onset hematemesis, melena, and abdominal pain. Two weeks prior, he presented to an outside hospital with abdominal pain and vomiting. He was found to have a 6.7 x 3.4 cm WON collection in the pancreatic tail on MRCP. EUS with FNA revealed necrotic debris and was negative for malignancy. Due to ongoing pain and poor oral intake, he underwent EUS-guided cyst-gastrostomy and necrosectomy 1 week later. A hot 10 x 15 mm lumen apposing metal stent (LAMS) was placed with balloon-dilation of the LAMS. Then, necrosectomy of cyst cavity was done via irrigation and suction with placement of coaxial double pigtail plastic stent. On presentation to our institution, he was afebrile and hypotensive, with a hemoglobin of 11.7 g/dL from 16.2 g/dL one week prior. Emergent abdominal CT angiogram revealed pigtail stent migration into the splenic arterial branches at the splenic hilum, causing splenic artery injury and large splenic infarct. Interventional radiology performed successful coil embolization of the splenic artery with bleeding cessation. The patient progressed well and was discharged home. (Figure ) Discussion: While endoscopic cyst-gastrostomy provides safe and effective treatment of pancreatic WON, it still carries the potential for serious complications. Prior literature reveals endoscopic therapy has a 26-33% bleeding rate and a mortality rate of 5.8-11%. Stent migration is a relatively rare complication that occurs in 0.7% of patients. In our case, disruption of the splenic vasculature likely resulted from mechanical injury by the cyst-gastrostomy stent. CT angiography is the best initial diagnostic test with excellent sensitivity and specificity. Treatment usually involves transcatheter embolization or surgery for patients with persistent hemodynamic instability. Splenic vascular injury and infarcts, while infrequent, can still occur as immediate and delayed complications and endoscopists should be vigilant of their occurrence post-procedure.[2873] Figure 1. (1A) Gastric lumen with hemorrhagic material (A). Cyst-gastrostomy connecting stomach and pseudocyst (B). Wedge-shaped splenic infarct (C). (1A) Successful embolization of splenic artery branches with multiple coils (A).