KEYWORDS
End-stage renal disease
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gastric outlet obstruction
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hemodialysis
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intramural duodenal hematoma
INTRODUCTION
I ntramural duodenal hematoma is a rare condition, which develops after blunt abdominal
trauma.[1 ]
[2 ]
[3 ] It is also and less commonly reported as a complication of anticoagulant therapy,
blood dyscrasias, pancreatic disease, and collagen vascular disease.[1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ] Intramural hematoma of the duodenum has been reported as a complication of diagnostic
or therapeutic endoscopy.[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ] We report a rare case of gastric outlet obstruction caused by intramural duodenal
hematoma after hemoclipping and injection adrenaline 1:10,000 of bleeding duodenal
ulcer in a patient with end-stage renal disease on maintenance hemodialysis. In literature,
there are hardly any case reports of gastric outlet obstruction with the same etiology
and this is the first from India although cases of small bowel obstruction have been
reported.
CASE REPORT
A 77-year-old diabetic and hypertensive male patient with end-stage renal disease
on maintenance hemodialysis (thrice/week) was admitted with 1 week history of melena
and generalized weakness. He was not on any antiplatelet or anticoagulation therapy.
There was no history of abdominal pain or similar episode in the past. On investigation,
he was found to be severely anemic with hemoglobin (Hb) of 5.6 gm/dl. His serum creatinine
was 5.5 mg/dl and serum potassium - 7.5 mEq/L. He had a normal coagulation profile.
After initial management in intensive care unit with multiple blood transfusions and
anti-hyperkalemic measures, he was taken up for endoscopy. Endoscopy revealed a duodenal
bulb ulcer approximately 1 cm in diameter with visible vessel and active ooze (Forrest
type IB). D2 and D3 were normal. Combination therapy of hemoclipping of the visible
vessel followed by injection adrenaline 1:10,000 up to approximately 20 ml was done
in all four quadrants around the ulcer, and hemostasis was achieved. About 6–8 h later,
patient developed acute-onset, continuous, moderate to severe intensity nonradiating
epigastric pain which was managed with intermittent intravenous analgesics. At this
time, his amylase and lipase levels were within normal limits and electrocardiogram
ruled out any acute cardiac event. Over the next 12–24 h, pain intensity reduced but
did not subside completely, and he developed abdominal distension and persistent nonbloody
retention vomiting. Further, despite receiving 4 units of packed red blood cell transfusion
and no obvious blood loss from any site, he continued to have low Hb (6.5 gm/dl).
An urgent computed tomography (CT) whole abdomen with oral and intravenous contrast
(after clearance from nephrologist) was planned which showed a large hyperdense and
nonenhancing mass lesion likely hematoma, in the wall of second part of the duodenum
with severe narrowing of the lumen of the duodenum and nonenhancing soft tissue thickening,
fat stranding in anterior pararenal space with thickening of the right renal fascia
[Figure 1 ]. Compression at ampulla with mild dilatation of the upstream bile ducts was seen.
The stomach was also dilated. A relook endoscopy [Figure 2 ] was done with minimal air insufflation which revealed a hyperemic, eccentric, and
large intramural duodenal hematoma involving the second part of duodenum with luminal
compromise. Scope could not negotiate the narrowed lumen. Previous hemoclips were
seen in situ with no active bleeding from the ulcer site. In the absence of any gross signs of
sepsis, peritonism, obstructive jaundice, or pancreatitis, a combined decision with
surgical team to continue with conservative management was taken. A trelumina nasojejunal
feeding tube with a gastric suction port was placed across the lesion under fluoroscopic
and endoscopic guidance. During this period, he underwent heparin free hemodialysis.
He received nasojejunal feedings and was discharged from the hospital with feeding
tube in situ after a total stay of 2 weeks. He was followed up in outpatient department and resumed
oral feeds at week 3 which was changed to soft and then to normal diabetic renal diet
over 6–8 weeks. He is in a stable condition at 4 months of follow-up and undergoing
maintenance hemodialysis. In the absence of any published guidelines or any firm indication
and in view of significant clinical improvement on regular follow-ups plus financial
issues in our setup and last but not the least, radiation risks, any repeat endoscopic
or any radiological investigation during this period was not done.
Figure 1: Abdominal computed tomography shows a large hematoma involving the second part of
duodenum with gasric outlet obstruction. Size 27 KB. Dimensions 512 × 512 pixels
Figure 2: Relook endoscopy shows a large hematoma in the second part of duodenum with complete
luminal narrowing. Also seen are the hemoclips in situ
DISCUSSION
Iatrogenic duodenal intramural hematoma is a rare presentation and this is probably
the first case from India that presented as gastric outlet obstruction. In this case,
we think that the use of large amount of diluted approximately 20 ml of adrenaline
1:10,000 and needle trauma in high-risk patients such as end-stage renal disease and
cirrhosis created a potential space by raising a submucosal flap by hydrodissection,
embedding the vessel and allowing it to continue bleeding in the submucosal plane.
Once a potential space has been created, pressure of the arterial bleed led to formation
of massive dissecting intramural hematoma. Other likely possibilities in this case
are anticoagulation during previous hemodialysis and functional coagulopathy in end-stage
renal disease patients despite having normal coagulation profile might have increased
the risk of bleeding. Relative fixity of the duodenum in retroperitoneum, location
ahead of vertebral column and rich vascular plexus make duodenum vulnerable to this
unusual complication, especially following blunt trauma to abdomen and may lead to
trauma to the submucosal vessels and bleeding in predisposed individuals. Patients
with duodenal hematoma usually present with insidious onset of obstruction about 48
h after the initial injury. The obstructive symptoms are due to a gradual shift of
fluid into the hypertonic environment within the intramural hematoma, leading to compression
of the duodenum, as in this case. Hematoma usually involves the second and third part
of duodenum causing gastric outlet obstruction. Intramural hematoma of the duodenum
is treated with either conservative or surgical therapy. When conservative treatment
is not effective, other modalities such as surgical drainage (laparotomy, laparoscopic
drainage), ultrasound- or CT-guided drainage are used.[16 ] In addition, endoscopic incision and drainage techniques are also used in the treatment
as a more comfortable method.[17 ] In our case, as there was no emergent indication for any invasive treatment such
as sepsis, signs of peritonism, obstructive jaundice, or pancreatitis due to pressure
over the ampulla or continued bleeding so a decision to manage the patient conservatively
was taken. Gastric outlet obstruction due to the large hematoma resolved quickly because
of the rich blood supply of the duodenum.
CONCLUSION
It should be kept in mind that endoscopic hemostatic procedures, especially large
volume adrenaline injection as in this case, in the presence of conditions, predisposing
patients to bleeding (e.g., chronic renal failure and hepatic cirrhosis) may lead
to complications, and any deterioration should prompt a reassessment, utilizing imaging
methods as necessary. Intramural hematoma should be considered in differential diagnosis
for patients with no clinical evidence of bleeding (no hematemesis or melena) but
with reduced hematocrit levels after endoscopic intervention. In case of complications
such as sepsis, nonresolving complete luminal obstruction, acute pancreatitis secondary
to pressure on the ampulla, and obstructive jaundice develop and should have a low
threshold for other modalities of treatment.
Financial support and sponsorship
Nil.
