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DOI: 10.1055/s-0029-1214927
© Georg Thieme Verlag KG Stuttgart · New York
Intramural hematoma: a rare complication of endoscopic injection therapy for bleeding peptic ulcers
A. A. D. Sadio
Department of Gastroenterology
São
Teotónio Hospital
Av. Rei D. Duarte 3504
509
Viseu
Portugal
Fax: +351-232-420591
Email: anasadio@iol.pt
Publication History
Publication Date:
18 March 2011 (online)
Intramural hematomas of the gastrointestinal tract are a rare entity. We report two cases of intramural hematoma that developed following endoscopic therapy for bleeding ulcers.
Case 1: A 67-year-old man with diabetes was admitted to the intensive care unit for acute respiratory distress syndrome after a bout of pneumonia. He was being treated with prednisolone, ranitidine, and enoxaparin. Fourteen days later, his hemoglobin decreased from 9.6 g/dL to 6.7 g/dL and he was transfused with 3 units of packed red blood cells (with the hemoglobin rising to 10.2 g/dL). Endoscopy revealed oozing bleeding from an ulcer on the anterior wall of the duodenal bulb. Hemostasis was achieved by injecting 5 mL of diluted epinephrine (1 : 10 000) and 1 mL of absolute alcohol. However, after 3 days, the patient’s hemoglobin decreased again (from 9.1 g/dL to 7.8 g/dL). A second-look endoscopy showed a conspicuous, violet-colored bulge in the duodenum, which seemed to be an intramural hematoma ([Video 1]).
Quality:
This was confirmed by computed tomography ([Fig. 1]).
Conservative treatment was instituted, but 20 hours later, the patient developed acute abdomen. An emergency laparotomy revealed a large duodenal hematoma extending into the retroperitoneum, with necrosis of the posterior wall ([Fig. 2]).
The hematoma was drained and there were no surgical complications. However, the patient died 30 days later from respiratory failure.
Case 2: A 76-year-old man was admitted with angina and melena since 2 days. He had a history of myocardial infarction, which had been treated with clopidogrel and acetylsalicylic acid. His hemoglobin was 11.8 g/dL. Endoscopy revealed an oval ulcer on the posterior wall of the gastric antrum, with oozing bleeding. Hemostasis was achieved by injecting 4 mL of diluted epinephrine (1 : 10 000) and 0.5 mL of absolute alcohol. A second-look endoscopy, 24 hours later, revealed three intramural hematomas ([Fig. 3]).
Another endoscopy 6 days later showed complete resolution of the hematomas ([Fig. 4]).
The cause of most intramural hematomas is blunt abdominal trauma; however, they have also been reported to occur as a complication of anticoagulant therapy [1] and blood dyscrasias [2], and after endoscopic biopsy [3] or therapy [4] [5]. In this latter case, the use of large amounts of injected substances and antiplatelet/anticoagulation therapy may favour their development [4]. We believe that in our cases, the presence of comorbidities in the first patient and the excessive anti-aggregation therapy in the second patient were implicated in the development of the intramural hematomas.
Endoscopy_UCTN_Code_CPL_1AH_2AC
Competing interests: None
#References
- 1 Chaiteerakij R, Treeprasertsuk S, Mahachai V et al. Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review. J Med Assoc Thai. 2008; 91 1285-1290
- 2 Nogues A, Eizaguirre I, Sunol M et al. Giant spontaneous duodenal hematoma in hemophilia A. J Pediatr Surg. 1989; 24 406-408
- 3 Ghisban F K, Werner M, Vieira P et al. Intramural duodenal hematoma: an unusual complication of endoscopic small bowel biopsy. Am J Gastroenterol. 1987; 82 368-370
- 4 Rohrer B, Schreiner J, Lehnert P et al. Gastrointestinal intramural hematoma, a complication of endoscopic injection methods for bleeding peptic ulcers: a case series. Endoscopy. 1994; 26 617-621
- 5 Sugai K, Kajimara E, Mochizuki Y et al. Intramural duodenal hematoma after endoscopic therapy for a bleeding duodenal ulcer in a patient with liver cirrhosis. Intern Med. 2005; 44 954-957
A. A. D. Sadio
Department of Gastroenterology
São
Teotónio Hospital
Av. Rei D. Duarte 3504
509
Viseu
Portugal
Fax: +351-232-420591
Email: anasadio@iol.pt
References
- 1 Chaiteerakij R, Treeprasertsuk S, Mahachai V et al. Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review. J Med Assoc Thai. 2008; 91 1285-1290
- 2 Nogues A, Eizaguirre I, Sunol M et al. Giant spontaneous duodenal hematoma in hemophilia A. J Pediatr Surg. 1989; 24 406-408
- 3 Ghisban F K, Werner M, Vieira P et al. Intramural duodenal hematoma: an unusual complication of endoscopic small bowel biopsy. Am J Gastroenterol. 1987; 82 368-370
- 4 Rohrer B, Schreiner J, Lehnert P et al. Gastrointestinal intramural hematoma, a complication of endoscopic injection methods for bleeding peptic ulcers: a case series. Endoscopy. 1994; 26 617-621
- 5 Sugai K, Kajimara E, Mochizuki Y et al. Intramural duodenal hematoma after endoscopic therapy for a bleeding duodenal ulcer in a patient with liver cirrhosis. Intern Med. 2005; 44 954-957
A. A. D. Sadio
Department of Gastroenterology
São
Teotónio Hospital
Av. Rei D. Duarte 3504
509
Viseu
Portugal
Fax: +351-232-420591
Email: anasadio@iol.pt