Successful percutaneous treatment for massive hemorrhage due to infectious pseudoaneurysm in the abdominal wall after percutaneous endoscopic gastrostomy: a case report
© Fujita et al.; licensee BioMed Central Ltd. 2014
Received: 15 May 2013
Accepted: 2 May 2014
Published: 10 June 2014
Percutaneous endoscopic gastrostomy (PEG) is often performed for alimentation and to prevent weight loss in patients with feeding problems due to central neurologic diseases such as cerebral infarction or intracranial hemorrhage. Although infection at the skin site after PEG placement is a typical late complication of PEG, a ruptured infectious pseudoaneurysm caused massive bleeding adjacent to the tract is rare. Prompt treatment is required to avoid the hemorrhage shock, however surgical ligation is difficult to obtain the arrest of bleeding in damaged skin due to the infection.
A 70-year-old male was bedridden due a cerebral infarction suffered 1 year previously. APEG was placed because of feeding problems, and a push-type, 20-Fr gastrostomy tube was inserted through the anterior abdominal wall. On day 16 after PEG placement, the patient had massive bleeding from the PEG site due to the rupture of infectious pseudoaneurysm and developed a decreased level of consciousness and hypotension. Treatment by percutaneous direct injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol was performed and achieved good hemostasis is obtained.
A rare case of an infectious pseudoaneurysm that developed in the abdominal wall and caused massive bleeding at a PEG placement site was described. Percutaneous injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol under ultrasound guidance is an effective treatment in this case.
Keywordsn-butyl-cyanoacrylate-lipiodol Infectious pseudoaneurysm Abdominal wall Percutaneous endoscopic gastrostomy
In iatrogenic or infectious pseudoaneurysms due to surgery or other interventions, and in superficial pseudoaneurysms due to trauma, the usefulness of surgery, embolization, ultrasound-guided manual compression, and percutaneous thrombin injection has long been reported [1–3]. The usefulness of percutaneous injection of a mixture of NBCA-lipiodol has also been described in some recent reports [4, 5].
A 70-year-old male was bedridden due a cerebral infarction suffered 1 year previously. A PEG was placed because of feeding problems, and a push-type, 20-Fr gastrostomy tube (Neofeed PEG kit; Top Corporation, Tokyo, Japan) was inserted through the anterior abdominal wall under electronic gastroscopy assistance (Olympus GIF 260; Olympus Corporation, Tokyo, Japan).
Complications associated with percutaneous gastrostomy tube placement are broadly divided into early complications due to the procedure, such as bleeding or bowel perforation during PEG placement, and late complications, as in the present patient, that occur sometime after PEG placement [6, 7]. Most complications are infections of the skin site, and infections of the PEG tube site particularly tend to develop in patients with decreased immunity who are elderly or have poor nutritional status . Infections may be mild, but abscess formation in the skin may also occur . The present patient did not have abscess formation, but infection due to Psedomonas aeruginosa of the PEG site skin occurred, and together with this, an infectious pseudoaneurysm of the epigastric artery near the PEG tube developed.
Pseudoaneurysms in the gastric wall after PEG placement have been reported , but according to our literature search, an infectious pseudoaneurysm in the abdominal wall as in the present case has not been previously reported. If the infectious pseudoaneurysm ruptures, as in the present patient, bleeding can be life-threatening, and treatment such as surgery, embolization, compression, or percutaneous injection of a blood-clotting agent like thrombin is necessary [1–3]. Percutaneous injection is clearly less invasive than surgery or embolization, is convenient, and has recently become the treatment of first choice [4, 5]. Various types of clotting agents are used, but when thrombin, which is the most common, is used, its potent clotting effect can severely irritate the surrounding tissue, it tends to cause allergic reactions, and embolization of peripheral vessels occasionally occurs, which can lead to surrounding tissue damage .
In comparison, with a mixture of NBCA-lipiodol, the NBCA immediately causes polymerization with sodium ions in the blood, so blood coagulation occurs immediately [10, 11]. Thus, the blood clotting ability is potent, and irritation of the surrounding skin is less. Therefore, this is an appropriate clotting agent in cases of skin infection as in the present patient. In addition, by changing the NBCA-lipiodol mixture ratio, the clotting time can be adjusted. With a 1:1 ratio, blood polymerization and clotting are reported to occur in about 2 to 3 seconds, so selection of a 1:1 mixture ratio in the present patient led to good results [4, 10, 11].
A rare case of an infectious pseudoaneurysm that developed in the abdominal wall and caused massive bleeding at a PEG placement site was described. Compression of the bumper was attempted, but it was unsuccessful in achieving thrombosis. The injection of a mixture of NBCA-lipiodol into the infectious pseudoaneurysm under ultrasound-guidance rapidly led to thrombosis and hemostasis. We believe that this is an effective treatment in this case.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Maleux G, Stockx L, Brys P, Lammens J, Lacroix H, Wilms G, Marchal G: Iatrogenic pseudoaneurysm in the upper arm: treatmentby transcatheter embolization. Cardiovasc Intervent Radiol. 2000, 11: 140-142. 10.1016/S1051-0443(00)70073-X.View ArticleGoogle Scholar
- Cox GS, Young JR, Gray BR, Grubb MW: Ultrasound-guided compression repair of postcatheterization pseudoaneurysms: results oftreatment in 100 cases. J Vasc Surg. 1994, 19: 683-686. 10.1016/S0741-5214(94)70042-7.PubMedView ArticleGoogle Scholar
- Messina LM, Brothers TE, Wakefield TW, Zelenock GB, Lindenauer SM, Greenfield LJ, Jacobs LA, Fellows EP, Grube SV, Stanley JC: Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures. J Vasc Surg. 1991, 13: 593-600. 10.1016/0741-5214(91)90341-Q.PubMedView ArticleGoogle Scholar
- Aytekin C, Firat A, Yildirim E, Kirbas I, Boyvat F: Ultrasound-guided glue injection asalternative treatment of femoral pseudoaneurysms. Cardiovasc Intervent Radiol. 2004, 27: 612-615. 10.1007/s00270-004-0197-z.PubMedView ArticleGoogle Scholar
- Beres RA, Harrington DG, Wenzel MS: Percutaneous repair of breast pseudoaneurysm: sonographically guided embolization. Am J Roentgenol. 1997, 169: 425-427. 10.2214/ajr.169.2.9242746.View ArticleGoogle Scholar
- Keung EZ, Liu X, Nuzhad A, Rabinowits G, Patel V: In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy. J Am Coll Surg. 2012, 215: 777-786. 10.1016/j.jamcollsurg.2012.08.013.PubMedView ArticleGoogle Scholar
- Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P: Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand J Gastroenterol. 2012, 47: 737-742. 10.3109/00365521.2012.654404.PubMedView ArticleGoogle Scholar
- Petersen TI, Kruse A: Complications of percutaneous endoscopic gastrostomy. Eur J Surg. 1997, 163: 351-356.PubMedGoogle Scholar
- Fatade F, Axelrod D, Lien K, Kaplan D, Nagula S: Percutaneous endoscopic gastrostomy tube placement complicated by a gastric pseudoaneurysm and recurrent hemorrhage. Endoscopy. 2012, 44: 38-39.View ArticleGoogle Scholar
- Toriumi DM, Raslan WF, Friedman M, Tardys ME: Variable histotoxicity of histoacryl when used in a subcutaneous site: an experimental study. Laryngoscope. 1991, 101: 339-343.PubMedGoogle Scholar
- Cromwell LD, Kerber CW: Modification of cyanoacrylate for therapeutic embolization: preliminary experience. Am J Roentgenol. 1979, 132: 799-801. 10.2214/ajr.132.5.799.View ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.