2006 Epigastric Artery Aneurysm Bleeding Post-Percutaneous Endoscopic Gastrostomy

Abstract

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is commonly used to provide enteral nutrition in patients unable to maintain adequate nutrition orally. There is limited data on aneurysmal bleeding following PEG. When this occurs, it is typically severe and is a life-threatening complication leading to hemorrhagic shock. Prompt recognition and treatment are imperative to survival. Extensive literature review revealed five case reports of post-PEG pseudoaneurysm. We present a summary of reported cases and their respective management. CASE DESCRIPTION/METHODS: We present a case of a 50-year-old female, status post orthotopic liver transplant, who had a complicated post-op course and ICU stay. The patient developed a cerebral infarct in Pons region which led to dysphagia. Therefore underwent PEG tube placement by “pull” technique. Later on, the patient experienced recurrent episodes of PEG site bleeding. She underwent EGD which showed massive upper GI bleed from percutaneous endoscopic gastrostomy fistula tract. Hemostasis was initially achieved using bear claw but also required endoclips and surgical intervention in the end. CT imaging revealed a pseudoaneurysm at the PEG site within the rectus muscle, arising from the epigastric artery, measuring 19.8 mm × 17.8 mm. It was treated with thrombin injection. The resolution of aneurysmal bleed was confirmed on follow up imaging. DISCUSSION: We found 5 similar cases with patients 70 to 85 years old, who predominantly had a pull technique PEG tube placement. Imaging confirmed gastrostomy site pseudoaneurysm, involing left gastric or gastroepiploic artery, was a complication in all cases which were either treated by lipiodol injection, angiographic embolization and/or thrombin injection. Our patient had a pseudoaneurysm involving epigastric artery which is a novel presentation. Placement of PEG with transillumination carries a risk of rare complication if inserted in an upper triangle involving superior epigastric artery. Therefore an attempt must be made to keep PEG away from the superior epigastric triangle. Pull technique is used much more commonly and It is unlikely to be the cause of these aneurysmal complications however, data is limited and more review studies are needed. Also, more evidence is needed to compare outcomes of the transillumination method vs US/fluoroscopic guidance placement.