S6369 A Rare Outcome of Argon Plasma Coagulation (APC): Gastric Perforation

Introduction: Argon plasma coagulation (APC) is a minimally invasive endoscopic technique commonly used to manage gastrointestinal bleeding, ablate residual polypoid tissue, and treat gastric vascular ectasia. While generally safe, APC can occasionally result in serious complications. We present a rare case of gastric perforation following APC that necessitated extensive surgical intervention. Case Description/Methods: A 74-year-old man nursing home resident with a history of hypertension, hyperlipidemia, hypothyroidism, dementia, and coronary artery disease presented with large-volume hemoptysis after weeks of mild bleeding. He was not on anticoagulation or nonsteroidal anti-inflammatory drugs aside from aspirin. On admission, he was hemodynamically stable, with benign abdominal findings. Labs showed hemoglobin 9 g/dL (dropping to 7.6), platelets 121 K/µL, BUN 60, and creatinine 2.9. Computed tomography (CT) abdomen unremarkable. He was admitted to the intensive care unity, developed acute hypoxic respiratory failure, and was intubated. Bronchoscopy revealed clots in the vocal cords, right main bronchus, and lower lobe without active bleeding. Esophagogastroduodenoscopy (EGD) showed diffuse hemorrhagic gastritis with friable mucosa, ulcerations, and angioectasias; hemostasis was achieved using argon plasma coagulation and hemostatic spray.Within an hour, he developed abdominal rigidity and hypotension. Imaging showed pneumoperitoneum. His hemoglobin dropped to 5.5 g/dL, requiring transfusions. Emergent laparotomy revealed gastric perforation at the lesser curvature and a splenic laceration. He underwent gastric wedge resection, omental patch, and splenectomy. He received 9 units of packed red blood cells and 1 unit of fresh frozen plasma, with hemoglobin improving to 9.9 g/dL. Despite 10 days of antibiotics, he could not tolerate oral intake and required total parenteral nutrition. Renal function did not recover, likely due to acute tubular necrosis. He declined dialysis and feeding tube placement and was discharged home with hospice care per family decision. Discussion: APC is generally safe but can cause complications, including bleeding, ulceration, fistula, perforation, and rarely obstruction. A meta-analysis reported a 22.5% adverse event rate with APC in Barrett’s esophagus, including perforation. A study comparing 40 vs 60 watts APC in the colon found no difference in perforation rates. Gastric perforation is rare due to the thick wall of the stomach, and incidence data are lacking. However, conditions like ischemic or atrophic gastritis that can compromise the integrity of the gastric wall may increase perforation risk, warranting caution with APC use.