Purpose or Case Report: Endoscopy-guided and image-guided gastrostomy tube placements have similar complication rates and range from 0.4-22.5% and 13-43% respectively. Of these, vascular injury occurs in approximately 1.4-2.5%. Understanding the imaging features, clinical presentations, and management of rare, severe, gastrostomy-related complications is crucial for early, accurate diagnosis and favorable outcomes. We present a rare case of exclusively intragastric hemorrhage from iatrogenic injury of an inferior epigastric artery following percutaneous gastrostomy tube placement. Case Report: A 4-year-old male patient with chronic constipation, failure to thrive, and developmental delay was admitted for abdominal distention and dysuria. A barium enema and biopsy confirmed short-segment Hirschsprung’s disease. He subsequently underwent diverting descending colostomy/mucous fistula creation, and laparoscopic gastrostomy tube placement. The following day he had a large-volume hematemesis. Hemoglobin was found to be 6.7 g/dL down from 12.4 g/dL preoperatively. Dark bloody output was noted in the gastrostomy tube trap. Emergent endoscopy demonstrated a massive amount of clot in the gastric lumen, and an obvious active bleed at the gastrostomy site with blood tracking along the gastrostomy tube stem. There was no evidence of hematoma or hemorrhage outside of the stomach by physical exam or endoscopy. A single bleeding vessel or pinpoint site amenable to endoscopic intervention was not identified. The patient proceeded to interventional radiology where initial angiography failed to identify an arterial source of bleeding involving the area suspected by endoscopy. The decision was made to empirically embolize the right gastroepiploic artery with gelfoam pledgets and slurry, as it was a low-risk intervention and the most likely source of arterial perfusion to the gastrostomy site. Further interrogation ultimately led, however, to identification of an active intragastric hemorrhage arising from a branch of the left inferior epigastric artery which was coil embolized. The patient recovered without incident and was discharged home 11 days later.
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Conclusions: Iatrogenic injury of the inferior epigastric artery while rare, should be considered in the differential diagnosis of patients with acute, exclusively intragastric hemorrhage following percutaneous gastrostomy tube placement.