Coil valve syndrome: a rare complication of percutaneous transhepatic obliteration successfully treated by argon plasma coagulation and double-balloon endoscopy

Percutaneous transhepatic obliteration (PTO) is now widely used for prophylactic treatment of gastric varices [1]. A straying coil tip in the stomach is sometimes reported as an adverse event [2] [3], but there have been no reports of one reaching the small intestine from the stomach.

In this case, the migrated coil tip with food residue was shaped like a ball and passed into the jejunum, causing a phenomenon resembling ball valve syndrome [4].

A 70-year-old woman was admitted with epigastric pain. She had been treated for gastric varices by PTO with coils ([Fig. 1]) 4 years earlier. One of these had migrated into the stomach asymptomatically 1 year after PTO ([Fig. 2]) and had been carefully monitored. Esophagogastroduodenoscopy on admission revealed the coil extending through the stomach and hooking into the mucosa at the angular portion of the stomach ([Fig. 3]). Abdominal computed tomography revealed that the coil tip was now in the jejunum ([Fig. 4]). Because of the risks of ulceration, perforation, or intussusception, we decided to remove it. Oral double-balloon enteroscopy (DBE) detected the coil tip enveloped by food residue in the jejunum; we carefully grasped it using forceps and pulled it back into the stomach. At first, we failed to cut the coil wire using a scissor-type electrical knife and loop cutter, but we finally succeeded in cutting it using argon plasma coagulation (APC) ([Video 1]). There were no adverse events during this procedure and the patient’s symptoms improved.

Fig. 1 Cerecyte coil.

Fig. 2 Endoscopic view of coil used to treat gastric varices, migrating from the fornix of the stomach (arrow).

Fig. 3 Endoscopic view of a migrated coil biting into the mucous membrane at the angular portion of the stomach.

Fig. 4 Computed tomography (CT) confirmed that the end of the coil was in the jejunum.

Video 1 “Coil valve syndrome”: a rare complication of percutaneous transhepatic obliteration for gastric varices that was successfully treated by argon plasma coagulation (APC) and double-balloon endoscopy (DBE).

The recovered coil was an 82-cm cerecyte coil. It was only possible to cut it using APC because the coil wire had unraveled and lengthened ([Fig. 5]). Compared with radiologists, few gastroenterologists know about migrated PTO coils and their characteristics.

Fig. 5 The recovered unraveled 82-cm cerecyte coil.

This case shows a rare complication of PTO that was successfully treated by APC and DBE. We propose to describe this “coil valve syndrome” as “ball valve-like syndrome due to deviated coil.”

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• References

• 1 Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med 1974; 291: 646-649
• 2 Kawai N, Minamiguchi H, Sato M. et al. Percutaneous transportal outflow-vessel-occluded sclerotherapy for gastric varices unmanageable by balloon-occluded retrograde transvenous obliteration. Hepatol Res 2013; 43: 430-435
• 3 Adebajo CO, Waxman I, Chapman C. et al. Foiled by coils: upper GI bleeding from a rare delayed adverse event of transarterial embolization. Gastrointest Endosc 2017; 85: 1295-1296
• 4 Hobbs WH, Cohen SE. Gastroduodenal invagination due to a submucous lipoma of the stomach. Am J Surg 1946; 71: 505-518