P0772 - Severe Gastrointestinal Bleeding Following Intrapleural Administration of Tissue Plasminogen Activator: A Case Report

Usman Shah, MBBS¹, Amr Aljareh, MD², Rahul Kumar, MD³, Shiny Teja Kolli, MD⁴, Vikash Kumar, MD⁵, Naresh Kumar, MD⁶, Shaheryar Siddiqui, MD^7
1North Central Bronx Hospital, Bronx, NY; ²NYC Health + Hospitals/Jacobi, Bronx, NY; ³Jacobi/ North Central Bronx Hospital Bronx, Bronx, NY; ⁴Jacobi Medical Center/North Central Bronx Hospital, Bronx, NY; ⁵Creighton University School of Medicine, Brooklyn, NY; ⁶The Brooklyn Hospital Center, Brooklyn, NY; ⁷Memorial Healthcare System, Houston, TX

Introduction: Tissue plasminogen activator (tPA) is widely used for its potent fibrinolytic properties in treating thromboembolic conditions. Intrapleural tPA is commonly employed to manage complex pleural effusions and empyema, enhancing drainage and resolving loculated effusions. Despite its localized application, intrapleural tPA can lead to systemic absorption and adverse effects, including bleeding. This case report highlights a rare instance of significant GI bleeding following intrapleural tPA administration. It underscores the importance of recognizing potential risks associated with this therapy and provides insights for clinicians to mitigate them in practice.

Case Description/Methods: A 78 years old male with PMH of HTN and CKD -3 was initially admitted for PNA with Parapneumonic effusion. On admission, labs showed mild leukocytosis, hemoglobin 12.2 g/dl, platelets 113 K, normal liver function tests (LFT), and coagulation profile. He was managed with antibiotics and treated with therapeutic thoracentesis with chest tube placement , was given intrapleural tPA and Dnase on the following day. Hospital course was complicated with new onset A-fib however anticoagulation was deferred due to recent tPA and managed with amiodarone. After 24 hours of tPA therapy, Patient had PEA arrest with ROSC after 14 mins and was intubated, Noted to have bright red blood from OG tube with melena. Post PEA labs showed significant drop to 6.6 g/dl, platelets 117, LFT consistent with shock liver and normal coagulation studies. Post arrest, CT head showed anoxic brain injury. GI was consulted, Patient was medically managed with PPI endoscopy was deferred due to the patient's poor neurologic status and hemodynamic instability. During MICU stay, patient hemoglobin remained stable with no further bleeding, but remained in vegetative state requiring tracheostomy for ventilatory support and was discharged to a long term assisted facility.

Discussion: Systemic tPA is known to carry a risk of gastrointestinal (GI) bleeding, but even intrapleural tPA administration, though rare, can lead to major GI bleeding. Intrapleural tPA, although effective for managing pleural effusions, can lead to significant systemic absorption and subsequent complications. This case underscores the importance of vigilance and proactive management strategies in patients receiving intrapleural tPA to ensure patient safety and optimal outcomes. Clinicians should remain aware of this potential complication and employ measures to mitigate the associated risks.


Disclosures:


Usman Shah, MBBS¹, Amr Aljareh, MD², Rahul Kumar, MD³, Shiny Teja Kolli, MD⁴, Vikash Kumar, MD⁵, Naresh Kumar, MD⁶, Shaheryar Siddiqui, MD⁷. P0772 - Severe Gastrointestinal Bleeding Following Intrapleural Administration of Tissue Plasminogen Activator: A Case Report, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.