What Is Too Big? Uterine Artery Embolization of a Large Fibroid Causing Abdominal Compartment Syndrome

A 39-year-old womanwith a history of spastic cerebral palsy, mental retardation, and chronic worsening nausea and vomiting presented to the emergency department from a group home with complaints of hematemesis. The patient was admitted to the hospital and underwent an upper endoscopy, which revealed a nonbleeding ulcer that was treated medically. The patient was advanced to a liquid diet and promptly became symptomatic again with nausea and guaiac-positive emesis. After further discussion with her caregivers, it became clear that the patient’s nausea and vomiting had been worsening before her admission. At this point, the patient’s prior radiologic studies were reviewed for a possible etiology. The patient had a computed tomographic (CT) scan of the abdomen and pelvis 5 months earlier that demonstrated multiple, large uterine fibroids, the largest measuring 16 cm 10 cm 10 cm (►Fig. 1). After multiple studies including an upper endoscopy, the gastroenterologist concluded that the patient’s hematemesis was likely due to reflux esophagitis frommass effect by the fibroids. The gynecologist was consulted regarding treatment for the large fibroids. A repeat CT of the abdomen and pelvis was performed that again demonstrated a multifibroid uterus with one prominent fibroid, unchanged from the previous study. Of note, the small bowel was unremarkable on this CT scan. The patient’s gynecologic workup was delayed, as the patient was transferred to the intensive care unit (ICU) for methicillin-resistant Staphylococcus epidermidis bacteremia, during which time the patient had a peripherally inserted central catheter placed and was started on total parenteral nutrition. Once the patient was medically stabilized, the gynecologist was again consulted and Lupron therapy was initiated for treatment of her fibroids. The patient’s hospital stay was further confounded by a biopsy of a left breast mass noted on mammography, which turned out to be a phyllodes tumor; in addition, she was treated for an unrelated Clostridium difficile infection during her admission. The patient’s nausea and vomiting continued to progress, at which point gastroenterologist was again consulted. The gastroenterologist felt that a feeding gastrostomy tube was not indicated, as the patient’s symptomswere likely related to small bowel obstruction from the uterine fibroids. Interventional radiologist placed a gastrojejunostomy tube, after which the patient was placed on wall suction due to continued symptoms and high gastric outputs. After improvement of her symptoms, tube feeds were initiated; this caused increased nausea and vomiting, again leading to the theory that her fibroids were causing mechanical obstruction. A repeat CT of the abdomen and pelvis was performed, which demonstrated a small bowel obstruction as a result of her uterine fibroids (►Fig. 2). The patient was scheduled for a hysterectomy and left mastectomy but developed a fever (temperature, 101.3°F) and became hypotensive to 77/46 mm Hg. Multiple blood cultures drawn at this time were positive for Candida parapsilosis, and the surgery was canceled. Further workup revealed a vegetation on the mitral valve; however, cardiothoracic surgery determined the patient was too cachectic to proceed with operative repair. After approximately 2-month hospital stay, the patient was discharged to her group home on tube feeds, Reglan, and Prevacid, and instructed to follow up with interventional radiologist for evaluation for uterine artery embolization (UAE), as she was deemed too poor a surgical candidate for hysterectomy. Approximately 2 months later, the patient had a magnetic resonance imaging scan of the pelvis, again demonstrating the multifibroid uterus with a large pedunculated fibroid (►Fig. 3). She subsequently underwent bilateral UAE. Upon initial aortic injection, markedly enlarged bilateral uterine arteries were seen, the right greater than the left, as well as a hypervascular enlarged fibroid uterus and a prominent right