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]).
Video
1 Endoscopy showing oozing
bleeding from an ulcer on the anterior wall of the duodenal bulb; hemostasis
was achieved with 5 mL of diluted epinephrine
(1 : 10 000) along with 1 mL of absolute alcohol.
Three days later, endoscopy showed a prominent violet-colored bulge,
corresponding to an intramural hematoma.
This was confirmed by computed tomography ([Fig. 1]).
Fig. 1 Computed tomography scan
showing an inhomogeneous, hyperdense mass,
10 × 7.5 cm in size, in the duodenum wall.
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]).
Fig. 2 At surgery, a large
duodenal hematoma was visualized, with necrosis of the posterior wall and
extending into retroperitoneum.
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]).
Fig. 3 Second-look endoscopy
– 24 hours after hemostasis – showing three violet-colored bulges
in the posterior wall of the antrum, corresponding to intramural hematomas.
Another endoscopy 6 days later showed complete resolution of the
hematomas ([Fig. 4]).
Fig. 4 Endoscopy, 6 days later,
showing a longitudinal ulcer and complete resolution of the hematomas.
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
