P2572 - Splenic Embolization to Stop Refractory Isolated Gastric Variceal Bleeding

Christian Nehme, MD¹, Sami Ghazaleh, MD², Dipen Patel, MD, MBA¹, Ziad Abuhelwa, MD¹, Amna Iqbal, MD¹, Saif-Eddin Malhas, MD¹, Yasir Al-Alabboodi, MD¹, Ali Nawras, MD^2
1University of Toledo, Toledo, OH; ²University of Toledo Medical Center, Toledo, OH

Introduction: The differential diagnosis for a patient presenting with coffee ground emesis is broad. Isolated type 1 gastric varices are an uncommon cause of bleeding, and they are only seen in 1.6% of patients with gastric varices. We present a case of refractory gastrointestinal bleed found to be the result of an isolated type 1 gastric varices.

Case Description/Methods: A 57-year-old male with a past medical history of diverticulosis presented to the hospital with an episode of coffee ground emesis. This was associated with nausea and melena. Patient reports a history of heavy NSAIDs use, but no previous history of upper gastrointestinal bleeding.




On presentation, patient had an episode of hematemesis. His vital signs were significant for a heart rate of 140 beats/min and a blood pressure of 78/35 mm/Hg. Physical exam was unremarkable. Labs showed a white blood cell count of 15.3 x 10⁹/L, hemoglobin of 7.3 g/dl (baseline was 13.5 g/dl), and platelets of 205 x 10⁹/L. INR was 1.1.




Patient was admitted to the ICU, and he was started on octreotide and protonix infusions. His hemoglobin continued to drop requiring 7 units of pRBCs. EGD was done the next day, and it showed dieulafoy lesions in the stomach and type 1 isolated gastric varices S/P epinephrine injections and two clips. CT angiogram abdomen showed no active source of arterial bleeding. It showed numerous vessels at the superior pole of the spleen.




Two days later, patient had another episode of hematemesis with hemodynamic instability. Repeat EGD showed actively bleeding isolated gastric varix at the greater curvature of the gastric fundus which was ligated with two rubber bands. As patient remained hemodynamically unstable, he underwent arteriography and splenic embolization, especially of the upper pole, with improvement in his symptoms.

Discussion: The most likely causes of the isolated gastric varices in this patient are either some sort of vascular malformation in the superior portion of the spleen or segmental venous thrombosis with development of the varices. As the patient’s condition was critical, it was decided to proceed with embolization at the risk of him needing a splenectomy later. The prominent upper pole vessels were aggressively embolized to diminish pressure within the splenic vein, which was patent, and to lessen the flow of blood into the gastric varices. That was successful in stopping the bleeding though the patient needed a splenectomy during his stay.



Disclosures:


Christian Nehme, MD¹, Sami Ghazaleh, MD², Dipen Patel, MD, MBA¹, Ziad Abuhelwa, MD¹, Amna Iqbal, MD¹, Saif-Eddin Malhas, MD¹, Yasir Al-Alabboodi, MD¹, Ali Nawras, MD². P2572 - Splenic Embolization to Stop Refractory Isolated Gastric Variceal Bleeding, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.