Introduction: Non-variceal upper GI bleeding is a medical emergency with high morbidity in elderly patients. While most cases are managed successfully with endoscopy, 5–10% require IR intervention. Failure of endoscopic hemostasis can be due to obscuring clot or variant vascular anatomy, such as an accessory left gastric artery. Splenic infarction following embolization is rare but should be considered in post-procedure care. Description: A 78-year-old man with CAD, GERD, prior duodenal ulcer bleed, hypothyroidism, and prior DVT (off anticoagulation, s/p IVC filter) presented with melena, dizziness, and hypotension. Hemodynamically optimized initially with IV fluid and 2 Units of PRBC transfusion. Initial CTA showed gastric clots but no active bleeding. Despite supportive care, he developed massive hematemesis and shock requiring ICU transfer, vasopressors, intubation, and activation of a massive transfusion protocol. Emergency bedside EGD revealed over 2 liters of retained clot and diffuse gastritis with no visible bleeding source. Repeat CTA abdomen and pelvis revealed active bleeding from an accessory left gastric artery originating from the inferior phrenic artery. Super-selective embolization using coils and gel foam achieved immediate hemostasis. Follow-up CT showed gastric decompression but revealed new wedge-shaped splenic hypodensities consistent with segmental infarctions, likely due to disrupted short gastric collateral flow. The patient had mild LUQ pain without a fever or leukocytosis and was managed conservatively. A second EGD on day 5 showed no active bleeding. He tolerated diet advancement and was discharged on day 12 with stable hemoglobin and outpatient follow-up. Discussion: Endoscopic failure in posterior gastric bleeding may result from deep submucosal vessels supplied by variant arteries. Recognition of an accessory gastric artery from the inferior phrenic artery was crucial. Splenic infarction is an underrecognized complication of proximal gastric embolization, often manageable conservatively. This case highlights the importance of recognizing vascular variants, early IR escalation in massive GI bleeding, and monitoring for ischemic complications like splenic infarction.
Subedi et al. (Sun,) studied this question.