
==== Front
Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00783-0
10.1016/j.radcr.2024.07.195
Case Report
Advanced management of postoperative hemorrhage following gastric bypass surgery through super-selective celiac artery coil embolization
Arain Nimra Razaque MBBS nimraarain_1993@hotmail.co.uk
a⁎
Fatima Laveeza MBBS b
Arain Umair Razaque MRCS c
Khan Ahmed Kamal Nasir FCPS, FRCR c
a South City Hospital, Karachi, Pakistan
b Allama Iqbal Medical College, Lahore, Pakistan
c James Paget University Hospital, Great Yarmouth, UK
⁎ Corresponding author. nimraarain_1993@hotmail.co.uk
30 8 2024
11 2024
30 8 2024
19 11 53805383
15 7 2024
30 7 2024
31 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A 36-year-old male presented with dizziness and melena 5 years post laparoscopic Roux-en-Y gastric bypass (LRYGB). Initial treatments with proton pump inhibitors and blood transfusions was followed by esophagogastroduodenoscopy (EGD) and CT angiography, identifying an active arterial bleed at the gastrojejunal anastomosis. Super-selective celiac artery coil embolization successfully controlled the bleeding. This case highlights the importance of considering late-onset gastrointestinal bleeding as a potential complication post-LRYGB. Early diagnosis and intervention, including advanced radiological techniques, are crucial for successful management and optimal patient outcomes.

Keywords

Gastric bypass surgery
Gastrointestinal bleeding
Late-onset bleeding
Super-selective embolization
Case report
==== Body
pmcBackground

Gastric bypass surgery has seen a significant increase due to the global obesity epidemic, advances in surgical techniques, increased awareness of obesity-related health issues, and expanded insurance coverage. Despite its benefits, postoperative bleeding, though relatively infrequent, remains a serious complication. This issue necessitates careful monitoring and prompt intervention by healthcare providers.

Postoperative bleeding following gastric bypass surgery is typically rare but poses significant risks when it occurs. Early postoperative hemorrhage has an incidence rate ranging from 2.6% to 3.1% according to recent studies. Most cases present within the first 3 postoperative days, with symptoms like tachycardia and abdominal pain being common. Studies have identified that early postoperative bleeding is associated with factors such as male gender, older age, and a history of revisional Roux-en-Y gastric bypass (RYGB) surgeries [[1], [2], [3]].

Management of postoperative hemorrhage includes withdrawing anticoagulant medications, providing hemodynamic support, and administering blood transfusions as needed. In some cases, reoperation is required, which can be performed laparoscopically or through open surgery if necessary. Super-selective celiac artery coil embolization has been highlighted as an advanced technique for managing severe cases of postoperative hemorrhage. This method involves using imaging guidance to place coils within the arteries feeding the bleeding site, effectively controlling the hemorrhage while preserving surrounding tissues [1,2]. Long-term complications, such as bleeding occurring years after surgery, are particularly challenging to manage. The incidence of such delayed bleeding is lower compared to early postoperative bleeding, but the risks remain significant. Studies have shown that late bleeding complications can stem from factors like marginal ulcers or staple line disruptions. Continuous follow-up and prompt medical attention are crucial for patients with a history of gastric bypass surgery to mitigate these risks [2,3].

In conclusion, while the overall risk of postoperative hemorrhage following gastric bypass surgery is low, the potential severity of such bleeding necessitates vigilant monitoring and advanced management strategies, including techniques like super-selective celiac artery coil embolization, to ensure patient safety and positive surgical outcomes.

Case presentation

A 36-year-old male presented to the emergency department with complaints of dizziness and melena persisting for 1 day. Laboratory investigations revealed a hemoglobin level of 7.5 g/dL (reference range: 13.8-17.2 g/dL). His medical history included a laparoscopic Roux-en-Y gastric bypass (LRYGB) performed nearly 5 years prior, with no other significant comorbidities.

Upon admission, the patient was administered proton pump inhibitors and received a transfusion of 3 units of packed red blood cells, resulting in an increase in hemoglobin levels to 9 g/dL. An esophagogastroduodenoscopy (EGD) was conducted to identify the source of bleeding, revealing exposed staples on the mucosal aspect without active bleeding. Despite these interventions, the patient continued to exhibit melena.

A subsequent CT angiogram identified an active arterial bleed at the gastrojejunal anastomosis (shown in Fig. 1, Fig. 2). A repeat EGD by the surgical team revealed ongoing mucosal bleeding. Initial hemostatic attempts using adrenaline injection and hemoclips were unsuccessful. As the patient's condition deteriorated, an angiography was performed under anesthesia, followed by coil embolization of the bleeding vessel in the gastric region.Fig. 1 Unenhanced axial CT scan.

Fig 1

Fig. 2 Enhanced CT scan showing extravasation of contrast from the site of gastrojejunostomy anastomosis (indicated by white arrow).

Fig 2

The angiographic procedure involved selective catheterization of the celiac artery, with visualization of the gastroepiploic and left gastric arteries. An ectatic vessel at the site of the endoscopic clip was identified (displayed in Fig. 3). The feeding artery was super-selectively cannulated, and embolization was achieved with coils measuring 2 × 20 mm and 3 × 30 mm. An additional small vessel leading to the clip was also embolized using a 3 × 20 mm coil. Subsequent catheterization of the superior mesenteric artery with imaging of the jejunal branches confirmed the absence of further complications (shown in Fig. 4).Fig. 3 Selective catheter angiography of Celiac axis showing vascular/contrast blush suggesting extravasation (indicated by white arrow).

Fig 3

Fig. 4 Successful post coiling; angiography shows no more contrast blush.

Fig 4

Postoperatively, the patient was monitored in an intensive care unit. Over the following 24 hours, bleeding gradually subsided, and repeat angiography the next day showed no active bleeding. The patient's condition improved, and dietary recommendations included a soft diet for 5 days, gradually transitioning to a regular diet while avoiding spicy foods, NSAIDs, tea, coffee, chocolate, and carbonated beverages. A follow-up appointment was scheduled for 1 week later, with a complete blood count (CBC) assessment included.

Discussion

We present a case of a rare complication following laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery, specifically late-onset gastrointestinal bleeding, and to discuss its successful management through super-selective celiac artery coil embolization. Previous literature acknowledges the occurrence of postoperative complications following gastric bypass surgery, including early and late postoperative bleeding. Early postoperative hemorrhage has been documented with incidence rates ranging from 2.6% to 3.1%, typically presenting within the first few postoperative days. Late-onset bleeding, occurring years after surgery, is less frequently reported but poses significant clinical challenges. Studies have explored various etiologies for late-onset bleeding, including marginal ulcers, staple line disruptions, and ectatic vessels. The rarity of late-onset gastrointestinal bleeding after LRYGB surgery is evidenced by the limited number of documented cases in the literature. This condition is particularly challenging due to its delayed presentation, often years after the initial surgery. The ectatic vessel observed in this case suggests a potential link to long-term vascular changes at the anastomotic site, which could predispose to bleeding.

In this case, the patient presented with dizziness and melena 5 years post-LRYGB, indicating a delayed onset of gastrointestinal bleeding. Initial management included proton pump inhibitors and blood transfusions. However, the persistence of melena necessitated further investigation through EGD and CT angiography, which identified an active arterial bleed. The decision to perform super-selective celiac artery coil embolization was based on the need for precise control of the bleeding vessel, minimizing the risk of ischemic complications. The use of super-selective coil embolization effectively controlled the bleeding, demonstrated by the cessation of melena and the absence of active bleeding on repeat angiography. The patient's stable postoperative course and absence of ischemic complications underscore the efficacy of this approach in managing complex cases of gastrointestinal bleeding post-LRYGB.

This case differs from the usual postoperative care for gastric bypass patients due to the delayed presentation and the complexity of managing late-onset bleeding. Recommendations for similar cases include early imaging and endoscopic evaluation in patients with unexplained gastrointestinal symptoms postbariatric surgery and the consideration of advanced interventional radiology techniques, such as super-selective embolization, for effective hemorrhage control. The key clinical message from this case is the importance of considering late-onset gastrointestinal bleeding as a potential complication in patients with a history of gastric bypass surgery, even years after the procedure. Prompt diagnosis and intervention are critical to managing such cases effectively.

Bleeding complications after gastric bypass surgery are more common in the immediate postoperative period, within the first few weeks or months. This is typically when complications related to the surgery itself or the staple lines are more likely to occur. However, as time passes and the surgical site heals, the risk of bleeding decreases. While long-term bleeding is relatively rare, it is not impossible. Factors such as the development of ulcers, irritation of the gastric pouch or anastomosis, or the use of blood-thinning medications can increase the risk [4]. Patients who experience any symptoms of gastrointestinal bleeding, such as dark or bloody stools, should seek medical attention promptly, even years after the surgery. Massive late hemorrhages, occurring more than 30 days after the operation, are rare occurrences and can occur even as late as 25 years postsurgery [4]. Late bleeding following gastric bypass surgery can commonly be attributed to various factors, including severe gastritis, marginal ulcers at the gastrojejunostomy (GJ) site, ulcers in the pouch, or issues within the gastric remnant stomach or duodenum [5]. Contributing factors can be categorized as patient-related, including the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and tobacco consumption, or local factors such as anastomotic tension and heightened gastric acid production [[6], [7], [8]]. It is important for individuals who have undergone gastric bypass surgery to maintain regular follow-up appointments with their healthcare providers to monitor their health and address any potential complications that may arise over time.

Although uncommon causes of late bleeding have been documented in the literature, to our knowledge, there have been no reported cases where bleeding was managed with super-selective multiple coil embolization of an ectatic vessel. Nevertheless, when such cases do arise, prompt and effective management becomes crucial, especially when conservative measures prove ineffective. This case highlights the significance of diagnostic and interventional radiology in successfully addressing a ruptured artery following gastric bypass surgery, even several years postoperation, and effectively precluding the need for further surgical intervention. Super-selective embolization is a safe and effective therapeutic approach for addressing acute lower gastrointestinal (GI) bleeding in a significant number of patients. Achieving success in this procedure is contingent on the careful application of technique and the selection of a suitable embolic agent, with an initial success rate of 100 percent [9]. As indicated in the literature, the use of super-selective arterial embolization has been established as an effective method for the prompt and secure management of upper gastrointestinal (GI) bleeding. This study adds to the body of evidence supporting this approach [[10], [11], [12]].

Outcome and follow-up

As a result of this radiological intervention, the patient was able to resume a regular diet and return to daily activities, thereby obviating the necessity for an open surgical procedure.

Ethical considerations

We confirm that approval for publication has been provided by the institution, its legal representative, and an ethics committee, in accordance with local legislation.

Patient consent

Written, informed consent for the publication of this case was obtained from the patient.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments: The authors have no acknowledgements to declare. The authors declare that no specific funding was received for this study.
==== Refs
References

1 Pavone G Gerundo A Pacilli M Fersini A Ambrosi A Tartaglia N. Bariatric surgery: to bleed or not to bleed? This is the question BMC Surg 22 2022 331 10.1186/s12893-022-01783-w 36058915
2 Nguyen NT Longoria M Chalifoux S Wilson SE. Gastrointestinal hemorrhage after laparoscopic gastric bypass Obes Surg 14 10 2004 1308 1312 10.1381/0960892042583997 15603643
3 Paige JT Gouda BP Gaitor-Stampley V Chauvin SW. No correlation between anti-factor Xa levels, low-molecular-weight heparin, and bleeding after gastric bypass Surg Obes Relat Dis 3 4 2007 469 475 10.1016/j.soard.2007.04.005 17567541
4 Rabl C Peeva S Prado K James AW Rogers SJ Posselt A Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies Obes Surg 21 3 2011 413 420 10.1007/s11695-011-0354-9 21240659
5 Gupta A Shah MM Kalaskar SN Kroh M. Late postoperative bleeding after Roux-en-Y gastric bypass: management and review of literature BMJ Case Rep 11 1 2018 e226271 10.1136/bcr-2018-226271
6 MacLean LD Rhode BM Nohr C Katz S McLean AP. Stomal ulcer after gastric bypass J Am Coll Surg 185 1 1997 1 7 9208953
7 Sapala JA Wood MH Sapala MA Flake TM. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients Obes Surg 8 5 1998 505 516 9819081
8 Goitein D Raziel A Szold A Szold A Goitein D. Sleeve gastrectomy as a single-stage bariatric operation for severe morbid obesity: role of serositis in postoperative morbidity J Am Coll Surg 210 4 2010 508 514 10.1016/j.jamcollsurg.2010.01.027
9 Grubnik VV Malynovskyy AV. Laparoscopic revisional surgery for marginal ulcer perforation after gastric bypass Obes Surg 24 5 2014 794 798 10.1007/s11695-013-1115-1
10 Matsumoto T Kuriyama S. Superselective embolization for acute lower gastrointestinal bleeding: short-term and long-term outcomes Cardiovasc Intervent Radiol 36 5 2013 1357 1365 10.1007/s00270-013-0560-7
11 Fang YM Chen WK. Efficacy of superselective embolization in acute upper gastrointestinal bleeding: a retrospective study J Clin Med 10 1 2021 123 10.3390/jcm10010123
12 Toci GR Ramalho J. Superselective arterial embolization for acute upper gastrointestinal bleeding: a systematic review Dig Dis Sci 64 12 2019 3597 3608 10.1007/s10620-019-05776-w
