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IVC filter perforation through the duodenum found after years of abdominal pain.

Jehangir A, Rettew A, Shaikh B, Bennett K, Jehangir Q, Qureshi A, Arshad S, Spiegel A - Am J Case Rep (2015)

Bottom Line: CT scan and EGD are valuable in the diagnosis.Excellent outcomes have been reported with open surgical filter removal.Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Reading Health System, West Reading, PA, USA.

ABSTRACT

Background: The number of IVC filter-related complications has increased with their growing utilization; however, IVC filter perforation of the duodenum is rare. It can manifest with nonspecific abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction.

Case report: A 67-year-old female presented with several years of right upper quadrant abdominal pain which was exacerbated by movement and food intake. She had a history of hepatic steatosis, cholecystectomy, and multiple DVTs with inferior vena cava filter placement. Physical exam was unremarkable. Laboratory tests demonstrated elevated alkaline phosphatase and transaminases. Esophagogastroduodenoscopy revealed a thin metallic foreign body embedded in the duodenal wall and protruding into the duodenal lumen with surrounding erythema and edema, but no active hemorrhage. Further evaluation with non-contrast CT scan revealed that one of the prongs of her IVC filter had perforated through the vena cava wall into the adjacent duodenum. Exploratory laparotomy was required for removal of the IVC filter and repair of the vena cava and duodenum. Her post-operative course was uneventful.

Conclusions: In patients with history of IVC filter placement with non-specific abdominal pain, a high clinical suspicion of IVC filter perforation of the duodenum should be raised, as diagnosis may be challenging. CT scan and EGD are valuable in the diagnosis. Excellent outcomes have been reported with open surgical filter removal. Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

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Related in: MedlinePlus

CT abdomen pelvis axial view revealing 1 of the anterior prongs of the IVC filter projecting through the vena cava wall into the adjacent third portion of the duodenum (white arrow). One of the posterior prongs is also projecting beyond the confines of the wall of the IVC into the anterior prevertebral fat (black arrow).
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f2-amjcaserep-16-292: CT abdomen pelvis axial view revealing 1 of the anterior prongs of the IVC filter projecting through the vena cava wall into the adjacent third portion of the duodenum (white arrow). One of the posterior prongs is also projecting beyond the confines of the wall of the IVC into the anterior prevertebral fat (black arrow).

Mentions: The patient underwent an EGD, which revealed normal mucosa of the esophagus and mild erythema of the mucosa of the stomach body and antrum; multiple cold forceps biopsies were performed. Rapid urea test was negative. Upon further advancement of the scope, a thin metallic foreign body was found in the 3rd portion of the duodenum, appearing to be sticking through the wall and with surrounding inflammation, but no active hemorrhage (Figure 1A, 1B). Possible differential included foreign body ingestion or perforating IVC filter through the wall of the duodenum. Post-procedure, she was clinically stable and denied any inadvertent foreign body ingestion. She was immediately sent to the emergency department for further evaluation. Her lab work showed persistently elevated liver enzymes with alkaline phosphatase of 162 (normal range 38–110 IU/L), AST 59 (9–33 IU/L), ALT 102 (2–38 IU/L), normal total and direct bilirubin, total protein, albumin, and INR. A non-contrast computerized tomography (CT) abdomen was obtained, which showed diffuse hepatic steatosis. Moreover, 1 of the anterior prongs of the IVC filter was projecting through the vena cava wall into the adjacent third portion of the duodenum (Figures 2 and 3). One of the posterior prongs was also projecting beyond the confines of the wall of the IVC into the anterior prevertebral fat (Figure 2). The patient was evaluated by a vascular surgeon, who felt no immediate surgical intervention was needed as the patient did not have any obstructive symptoms, there was no evidence of periduodenal inflammation or hemorrhage, and removal of the filter would require a major surgical procedure.


IVC filter perforation through the duodenum found after years of abdominal pain.

Jehangir A, Rettew A, Shaikh B, Bennett K, Jehangir Q, Qureshi A, Arshad S, Spiegel A - Am J Case Rep (2015)

CT abdomen pelvis axial view revealing 1 of the anterior prongs of the IVC filter projecting through the vena cava wall into the adjacent third portion of the duodenum (white arrow). One of the posterior prongs is also projecting beyond the confines of the wall of the IVC into the anterior prevertebral fat (black arrow).
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4447199&req=5

f2-amjcaserep-16-292: CT abdomen pelvis axial view revealing 1 of the anterior prongs of the IVC filter projecting through the vena cava wall into the adjacent third portion of the duodenum (white arrow). One of the posterior prongs is also projecting beyond the confines of the wall of the IVC into the anterior prevertebral fat (black arrow).
Mentions: The patient underwent an EGD, which revealed normal mucosa of the esophagus and mild erythema of the mucosa of the stomach body and antrum; multiple cold forceps biopsies were performed. Rapid urea test was negative. Upon further advancement of the scope, a thin metallic foreign body was found in the 3rd portion of the duodenum, appearing to be sticking through the wall and with surrounding inflammation, but no active hemorrhage (Figure 1A, 1B). Possible differential included foreign body ingestion or perforating IVC filter through the wall of the duodenum. Post-procedure, she was clinically stable and denied any inadvertent foreign body ingestion. She was immediately sent to the emergency department for further evaluation. Her lab work showed persistently elevated liver enzymes with alkaline phosphatase of 162 (normal range 38–110 IU/L), AST 59 (9–33 IU/L), ALT 102 (2–38 IU/L), normal total and direct bilirubin, total protein, albumin, and INR. A non-contrast computerized tomography (CT) abdomen was obtained, which showed diffuse hepatic steatosis. Moreover, 1 of the anterior prongs of the IVC filter was projecting through the vena cava wall into the adjacent third portion of the duodenum (Figures 2 and 3). One of the posterior prongs was also projecting beyond the confines of the wall of the IVC into the anterior prevertebral fat (Figure 2). The patient was evaluated by a vascular surgeon, who felt no immediate surgical intervention was needed as the patient did not have any obstructive symptoms, there was no evidence of periduodenal inflammation or hemorrhage, and removal of the filter would require a major surgical procedure.

Bottom Line: CT scan and EGD are valuable in the diagnosis.Excellent outcomes have been reported with open surgical filter removal.Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Reading Health System, West Reading, PA, USA.

ABSTRACT

Background: The number of IVC filter-related complications has increased with their growing utilization; however, IVC filter perforation of the duodenum is rare. It can manifest with nonspecific abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction.

Case report: A 67-year-old female presented with several years of right upper quadrant abdominal pain which was exacerbated by movement and food intake. She had a history of hepatic steatosis, cholecystectomy, and multiple DVTs with inferior vena cava filter placement. Physical exam was unremarkable. Laboratory tests demonstrated elevated alkaline phosphatase and transaminases. Esophagogastroduodenoscopy revealed a thin metallic foreign body embedded in the duodenal wall and protruding into the duodenal lumen with surrounding erythema and edema, but no active hemorrhage. Further evaluation with non-contrast CT scan revealed that one of the prongs of her IVC filter had perforated through the vena cava wall into the adjacent duodenum. Exploratory laparotomy was required for removal of the IVC filter and repair of the vena cava and duodenum. Her post-operative course was uneventful.

Conclusions: In patients with history of IVC filter placement with non-specific abdominal pain, a high clinical suspicion of IVC filter perforation of the duodenum should be raised, as diagnosis may be challenging. CT scan and EGD are valuable in the diagnosis. Excellent outcomes have been reported with open surgical filter removal. Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

Show MeSH
Related in: MedlinePlus