S2601 Gastroepiploic Pseudoaneurysm: A Shocking Complication of PEG Tube Placement

Introduction: Percutaneous gastrostomy (PEG) tubes are commonly used for enteric feeds and medication administration. While considered safe and routine, PEG tube placement is not without its complications. Here we present a rare case of hemorrhagic shock secondary to traumatic pseudoaneurysm formation after PEG tube placement. Case Description/Methods: A 52-year-old male with atrial fibrillation on apixaban and a recent stroke with PEG tube placement 1 month prior to arrival presented to the hospital with multiple episodes of hematemesis. CT angiography of the abdomen was unremarkable and negative for signs of active bleeding. Antiplatelets were held and anticoagulation was reversed with prothrombin complex concentrate. Esophagogastroduodenoscopy showed signs of erosive esophagitis with proper PEG tube placement but without signs of active bleeding. Hematemesis re-occurred less than 24 hours after anticoagulation was resumed, with subsequent development of hemorrhagic shock. Visceral arteriogram revealed a right gastroepiploic artery pseudoaneurysm, which likely developed from trauma during recent PEG placement. The patient stabilized after coil embolization and blood transfusion. He was then safely resumed on anticoagulation without further bleeding. Discussion: GI bleeding associated with PEG placement occurs in 0.6-1.2% of cases, and usually occurs at the gastrostomy tract or from gastric ulceration. Bleeding related to pseudoaneurysm formation is exceedingly rare with only a handful of case reports documenting such occurrence. While contrast enhanced imaging may aid in the diagnosis, small pseudoaneurysms may not be detected with noninvasive angiographic studies (as was the case here). Given this potentially life-threatening complication, clinicians must consider pseudoaneurysm formation as part of their differential for GI bleed after recent PEG placement especially if endoscopic evaluation is unrevealing.