Gastrointestinal hemorrhage consequent to foreign body reaction to silk sutures

Introduction: Nonabsorbable sutures used in gastric surgery have been associated with ulceration, pain syndromes, and N/V all of which may resolve with endoscopic or surgical removal. Bleeding associated with sutures is uncommon, massive bleeding is rare, and all have involved local ulceration. Methods: The clinical course of 3 patients with severe GI bleeding related to silk sutures, the local tissue reaction, and response to therapy were investigated. Results: Case 1: A 32 yo WM with antrectomy and vagotomy for DU had recurrent, unpredictable UGIBs requiring 4-6 units of blood over a six month period. Multiple upper endoscopies for massive hematemesis revealed only luminally oriented silk sutures, one of which bleed with tugging. Angiogram was unrevealing. In spite of surgical revision the silk sutures remained intact and massive bleeding reoccurred multiple times. Autopsy after exsanguination revealed a clot overlying the silk suture with fibrosis, chronic inflammatory infiltrate, no large arteries, and normal overlying mucosa. Special stains for smooth muscle showed proliferation of arterioles around the suture. Case 2: A 37 yo WM experienced numerous intermittent, unpredictable, massive UGIH for a 15 yr period after antrectomy and vagotomy for a bleeding DU where silk sutures were used. Upper endoscopy for hematemesis revealed pulsatile arterial bleeding from the base of a silk suture and no evident ulceration. After response to cautery, suture removal attempts were fruitless. Pt is free of UGIH 9 months after surgical resection and reanastomosis with absorbable sutures. Histological examination revealed cautery ulcer at the suture site, chronic and acute inflammation, and no large vessels. Case 3: A 72 yo WF with a subtotal gastrectomy for gastric lymphoma experienced melena and Fe-deficiency anemia. She underwent upper endoscopy which revealed luminally oriented silk sutures and no ulcerations. The sutures were removed endoscopically and a subsequent colonoscopy was normal. Anemia rapidly resolved and no melena or g+ stools has occurred after 6 months. Conclusion: Silk sutures used in gastric surgery can be a source of intermittent massive UGIH with no endoscopie evidence of mucosal ulceration. They apparently create a tissue foreign body reaction and dense microvascularity which may be the source of the bleeding.