Hematemesis after peroral endoscopic myotomy: always computed tomography-scan?

Peroral endoscopic myotomy (POEM) is a well-established therapy for achalasia. Although considered safe, postoperative adverse events might pose a challenge for the endoscopist. Bleeding usually occurs during the procedure; conversely, a delayed one is very uncommon (0.2%), with a higher incidence in the first 72 h. Literature about its treatment is poor and limited to case reports and series [1] [2] [3] [4] [5].

A 46-year-old man with type II achalasia underwent POEM, using a posterior approach, without complications ([Video 1]). After 24-hours, he started drinking clear fluid asymptomatically and was discharged on the second postoperative day. A soft purée diet and esomeprazole (40 mg BID) were prescribed and taken regularly. On the eighth post-operative day, he suddenly developed dysphagia, followed a few hours later by hematemesis. Fever, tachycardia, hypotension and chest pain were all absent. No drop of hemoglobin was found. An esophagogastroduodenoscopy (EGD) revealed an occluding clot in the esophageal lumen, successfully removed, without signs of hematoma [1] [2] ([Fig. 1], [Fig. 2]). Mucosotomy clips were dislodged and an ulceration at the site was detected ([Fig. 3]). Neither a computed tomography (CT) scan nor other procedures were performed. The patient continued fasting, proton pump inhibitors, monitoring parameters, and blood count for 24 hours, without any alterations. Then, he restarted the liquid diet. After 1 month from POEM, the patient resumed a free diet without complications.

Download Video

Endoscopic treatment and complication management.Video 1

Fig. 1 Occluding clot in the esophageal lumen.

Fig. 2 Esophageal endoscopic appearance after clot removal.

Fig. 3 Mucosotomy findings at EGD. Abbreviation: EGD, esophagogastroduodenoscopy.

Unlike other cases [1] [2] [3], our complication arose later, without the classical signs/symptoms (pain, hemodynamic alterations, and hemoglobin drop) described. Only two colleagues reported late delayed bleeding, but in symptomatic patients (hypotension, anaemia, or pain) [4] [5].

According to the current literature, our case seems unique in its presentation. His stability, the absence of other symptoms or endoscopic signs of hematoma, led us to successfully adopt a conservative management, without the need to expose this young patient to radiation of a CT scan.

In conclusion, given its rarity, also in light of what has been reported in the literature so far, the management of this complication should always be tailored to the individual patient.

Endoscopy_UCTN_Code_CPL_1AH_2AM

Publication History

Article published online:
26 November 2025

• References

• 1 Omella Usieto I, Santiago García J, de Frutos Rosa D. et al. Delayed bleeding and intratunnel hematoma after peroral endoscopic myotomy: salvage endoscopy management with full recovery. Endoscopy 2022; 54: 624-625
• 2 Li QL, Zhou PH, Yao LQ. et al. Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video). Gastrointest Endosc 2013; 78: 370-374
• 3 Benech N, Pioche M, OʼBrien M. et al. Esophageal hematoma after peroral endoscopic myotomy for achalasia in a patient on antiplatelet therapy. Endoscopy 2015; 47 (Suppl. 01) E363-E364
• 4 Liu X, Zhou Y, Jiang X. et al. Superselective arterial microcoil embolization for delayed bleeding after peroral endoscopic myotomy. J Int Med Res 2022; 50: 3000605221135475
• 5 Marrelli M, Biasutto D, Neri B. et al. Conservative Management of Delayed Submucosal Bleeding after Per-Oral Endoscopic Myotomy: A Case Report. Acta Med Litu 2024; 31: 388-393