Life-threatening bleeding from postbulbar duodenal ulcer saved by emergency transcatheter arterial embolization.

摘要

Immediate operation is the standard procedure to arrest life-threatening bleeding from postbulbar duodenal ulcer (PDU) not amenable to endoscopic treatment. Nonetheless, even in operable cases, mortality and morbidity rates for hemorrhagicPDUs are high. Here we report on a patient with life-threatening hemorrhage from PDU, who, after failed endoscopic treatment, was successfully saved by emergency transcatheter arterial embolization (TAE) with polyvinyl alcohol and gelatin sponge particles.A 69-year-old man underwent a coronary artery bypass graft for myocardial infarction, and was discharged 17 days later. Before and following the procedure, standard-dose histamine receptor antagonist was administered to the patient. Warfarin was given orally (Thrombotest, 10%-20%). Nonsteroidal anti-inflammatory drugs (NSAIDs) were not administered. On the next day, the patient presented at our institution unconscious (owing to hypovolemic shock) and with tarry stool. He was stabilized by rapid fluid resuscitation. Upper gastrointestinal endoscopydisclosed multiple, small, shallow ulcers in the postbulbar lesion of the duodenum, with bleeding from one of these ulcers. Hemostatic clips were used to control bleeding at the site. Nonetheless, the following day, hemorrhage recurred and the patient again went into shock. In this instance, endoscopic treatment was not feasible because hematoma obscured visualization of the bleeding site. Contrast-enhanced computed tomography (CT) images showed an intraluminal extravasation from the anterior wall of the duodenum. Emergency diagnostic angiography revealed extravasation from the duodenal branch arising from the anterior superior pancreaticoduodenal artery (ASPDA), and superselective TAE was performed immediately. The feeding branch was embolized using polyvinyl alcohol particles ranging in size from 500 to 700 mum (Ivaron, Contour; Boston Scientific, Fremont, CA, USA), beginning with the ASPDA. To ensure hemostasis,gelatin sponge particles (Gelfoam; Pharmacia and Upjohn, Kalamazoo, MI, USA) were added. Subsequent angiography showed complete occlusion. No increase in serum levels of transaminasesor amylase was noted. Improvement of PDUs (including the hemorrhagic ulcer) was achieved with proton pump inhibitor therapy, and duodenal ischemia was not observed. The serum gastrin level, which was elevated (307 pg/ml) before TAE, decreased to 101 pg/ml after the procedure (normal range, 37-172 pg/ml).The patient has been well and without recurrent ulcer formation or bleeding for 50 months.