Guitarist Pick for Melena : A Unique Case of an Upper GI Bleed

Gastrointestinal bleeds are a commonly observed complication after left ventricular assist device placement and usually caused by formation of arteriovenous malformations or acquired von Willebrand disease in the setting of anticoagulation use. We present a unique case of an upper GI bleed in which the cause was likely due to the impaction of a guitar pick into the duodenal bulb in the setting of continuous flow-LVAD on anticoagulation with elevated INR and discuss the pathophysiology of GI bleeds post-LVAD placement and relevant concerns about finding foreign bodies in the GI tract and their complications.


Introduction
Gastrointestinal bleeds are a commonly observed complication after left ventricular assist device placement [1].Most of these bleeds are due to formation of arteriovenous malformations or acquired von Willebrand disease in the setting of anticoagulation use [2] [3].We present a unique case of an upper GI bleed in which the cause was likely due to the impaction of a guitar pick (plectrum) into the duodenal bulb in the setting of continuous flow-LVAD on anticoagulation with elevated INR and presented with melena and symptoms of acute blood loss anemia.

Case Report
A 70-year-old male with past medical history of end stage ischemic cardiomyo- and acute blood loss anemia and started on proton pump inhibitor (PPI) infusion for upper gastrointestinal bleeding.Three units of packed red blood cells were given and gastroenterology was consulted.GI recommended proceeding with upper endoscopy (EGD), but was not able to perform the procedure initially due to the patient's elevated INR.Meanwhile, two more units of packed red blood cells were transfused with improvement of hemoglobin from 5.6 to 8.8.
Two days after admission, upper endoscopy was performed given INR 2.0.On EGD, diffuse mild inflammation characterized by linear erosions was found at the pylorus and a foreign body with small amount of oozing was seen in the duodenal bulb (Figure 1

Discussion
GI bleeds are a commonly observed complication after LVAD placement [1].
The incidence of GI bleed in patients with LVAD is estimated to be roughly 20%, and most of these patients have continuous flow (CF) LVAD [4].Most of the GI bleeds in these patients occur due to the formation of AVMs [2], which is thought to be caused by intestinal hypoperfusion from reduced pulse pressure in CF-LVADs leading to regional hypoxia and vascular dilation [5], but also due to an acquired von Willebrand disease, characterized by decreased or absent levels of high molecular weight von Willebrand factor multimers [2].The reduction in these factors is also thought to be secondary to the narrow pulse pressure in CF-LVADs, mimicking Heyde's Syndrome seen in aortic stenosis [3].In addition, CF-LVAD use requires the use of anticoagulation because of the hypercoagulable state associated with the device.Unfortunately, the risk for both thrombotic and hemorrhagic complications are increased compared to those on anticoagulation without LVAD, likely due to the impaired platelet aggregation secondary to acquired von Willebrand disease [2].
Our patient's initial presentation of melena and anemia suggested bleeding in the upper gastrointestinal tract, but this case is novel for the etiology of the bleed [6].Finding a foreign body in the duodenum in a patient with LVAD raised concern for fistula formation or erosion of the hardware into the duodenum.
Hence, the finding of such an object should raise concern for the endoscopist, and in our case, heart failure physicians were contacted for possible components of the LVAD into the duodenum.Fortunately, the word "Fender" was legible and thus helped with the conclusion that the foreign object is likely not a component of the LVAD.Given patient history of blindness and concern for foreign object, the patient's wife was contacted during the procedure prior to endoscopic retrieval.Foreign body ingestion is common, but the objects themselves typically pass without consequence and are thus rarely the cause of GI bleeding [7].However, it is observed that foreign body ingestion is increased in those with sensorial deficiency, like blindness in this patient [8].In conclusion, a thorough patient history at admission is important, and if a foreign body is found in the GI tract, it requires further investigation prior to retrieval.
Unsurprisingly, impacted foreign bodies in the GI tract lead to a high risk for the development of major complications such as perforated esophagus and mediastinitis, deep neck abscesses and aortoesophageal fistulas (AEF) [9].AEFs are associated with high morbidity and mortality, and more than 100 cases have been reported as being associated with foreign bodies [10].Therefore, the finding of an unsuspected foreign body in a patient with implanted devices should raise alarms for a possible fistula or erosion of the device into the GI tract.Thus, it is important to discuss with the surgeon or device manufacturer regarding the possible parts prior to tugging or removal.
In summary, it is suspected that the bleeding was likely due to the impaction of the guitar pick into the duodenal bulb in the setting of continuous flow-LVAD on anticoagulation with elevated INR, which led to acute blood loss anemia and the patient's presenting symptoms.After retrieval of the guitar pick, the patient was restarted on anticoagulation and discharged from the hospital in stable condition.

Figure 1 .
Figure 1.Endoscopic findings of a foreign body in the duodenal bulb.

Figure 2 .
Figure 2. Endoscopic images of Fender guitar pick during (a) and post-retrieval (b).