Acute duodenal intramural hematoma complicated by acute pancreatitis—a rare complication of endoscopic epinephrine injection therapy

Acute duodenal intramural hematoma complicated by acute pancreatitis—a rare complication of... Intramural duodenal hematoma (IDH) is a rare complication in endoscopic management of ulcer hemorrhage. Usually noted in cases of blunt abdominal trauma, non-traumatic IDHs have been reported in individuals on anticoagulation, with blood disorders, pancreatic diseases and in endoscopic procedures such as biopsy, sclerotherapy and argon plasma coagulation. Patients may be asymptomatic or present with acute blood loss anemia, abdominal pain or vomiting. We report a case of an 83- year-old man with melena and syncope who underwent endoscopy for bleeding ulcer control and subsequently developed acute pancreatitis due to an acute IDH. Computed tomography (CT) scan confirms the diagnosis. Most cases are conservatively managed however when unsuccessful, laparoscopic surgical drainage or ultrasound or CT guided drainage can be performed. and in endoscopic procedures such as biopsy, sclerotherapy INTRODUCTION and argon plasma coagulation [5]. We report a case of an 83- Endoscopic modalities for hemostasis in active gastrointestinal year-old man with melena and syncope who underwent bleeding have evolved over the years. Their effectiveness has endoscopy for bleeding ulcer control and subsequently devel- now made endoscopic management the treatment of choice in oped acute pancreatitis due to an acute IDH. We report on the active ulcer hemorrhage [1]. Sclerotherapy is a safe and effective clinical presentation, and discuss treatment and management modality of hemostasis in bleeding ulcers however there may of this complication. exist some serious associated complications [2]. These complica- tions include mucosal perforation, and ulceration, vessel throm- CASE REPORT bosis and bleeding culminating in serious adverse events [2, 3]. Intramural duodenal hematoma (IDH) is a rare complication An 83-year-old man with medical history of hypertension, dia- in endoscopic treatment of ulcer bleeding. IDHs are usually found betes mellitus type 2, Alzheimer’s dementia and chronic consti- in casesofblunt abdominal trauma[4]. However, non-traumatic pation, presented with dizziness and lightheadedness. He also hematomas have been reported in patients on anticoagulation, reported melena of 5 days duration, which was associated with individuals with underlying blood disorders, pancreatic diseases mild epigastric pain. Physical examination revealed an elderly Received: September 30, 2017. Revised: October 30, 2017. Accepted: November 10, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx090/4821286 by Ed 'DeepDyve' Gillespie user on 16 March 2018 38 E. Ofori et al. male in no acute distress. Abdominal examination was unre- associated intra-peritoneal and extra-peritoneal hematoma markable. Laboratory findings noted hemoglobin 12.3 g/dL, plate- (Fig. 4). Patient’s hemoglobin subsequently improved to 10.1 g/dL let count 239, lipase 28 U/L and INR of 1.1. Further questioning without further PRBC transfusions. Patient was subsequently dis- revealed, he had undergone an esophagogastroduodenoscopy charged home to follow up in the clinic. (EGD) at an outside institution ~2 weeks prior for abdominal pain and he was unsure of the findings. Computed tomography (CT) DISCUSSION scan of abdomen showed uniform mural thickening of gastric IDHs are rare complications in endoscopic management of antrum, and normal appearing pancreas (Fig. 1). Patient’sdizzi- gastrointestinal bleeding. IDHs are however common in cases ness persisted, and hemoglobin dropped to 9.0 over the next 24 h. of blunt abdominal trauma with over half cases occurring in An urgent EGD revealed patchy erythematous gastropathy, and a children under age 15 [4, 6]. IDHs are commonly found in the briskly bleeding site noted in the second portion of the duodenum second and third portions of the duodenum [7]. The close prox- ~4 cm proximal to the ampula of Vater. The mucosa was edema- imity of the second and the third portions of the duodenum to tous but without discernable ulcer (Fig. 2). Hemostasis was the posterior vertebral bodies, coupled with their high sub- achieved with application of 5 mL of 1:10 000 epinephrine injec- mucosal vascularity and fixation by the peritoneum predis- tion and placement of a hemostatic clip. poses these segments of the duodenum to injury including Over the next day, the patient reported worsening epigastric intramural hematomas [8]. Non-traumatic cases of intramural pain and tenderness associated with non-bilious non-bloody hematomas have been reported, usually in patients on anticoa- emesis. Lipase returned elevated at 1235 U/L. He was initiated on gulation, individuals with underlying blood disorders, pancre- intravenous hydration with lactate ringers and was kept nothing atic diseases and in endoscopic procedures such as biopsy, by mouth. CT scan of abdomen showed an ill-defined, ovoid het- sclerotherapy and argon plasma coagulation [5]. erogeneous hyper attenuating structure distal to the hemostatic IDH presents in a variety of ways. Patients may present with clip, expanding the second portion of the duodenum and meas- 2 acute blood loss anemia, abdominal pain, vomiting or may even uring 5.5 × 3.8 cm , most likely representing an intramural hema- be asymptomatic. Very few (<30) cases of IDH after biopsy or toma along with peri-pancreatic edema representing acute sclerotherapy have been reported in the literature to our knowl- pancreatitis (Fig. 3). Hemoglobin trended down to 7.3 g/dL which edge [9]. Most of these patients with IDH after hemostatic ther- responded appropriately with the transfusion of a unit of packed apy had underlying coagulopathy, thrombocytopenia and/or red blood cell (PRBC). Abdominal pain and tenderness resolved liver cirrhosis [4, 7, 9–12]. Dibra et al. [13] however reported a over the subsequent 2 days. A repeat CT scan of abdomen case of IDH after submucosal epinephrine therapy for duodenal showed an interval decrease in size of the IDH and also the bleeding ulcer in a patient without apparent underlying disease. Additionally, all the cases of IDH had a common variable of epi- nephrine injection therapy performed while some had an added combination of ethanolamine injections or hemostatic clipping. Some cases of IDH had an associated acute pancreatitis, theo- rized to be likely due to compression of the ampulla of Vater by the hematoma [14]. Our patient has a similar associated acute pancreatitis but without any known underlying coagulopathy or cirrhosis. The development of acute pancreatitis in cases of IDH has been attributed to hematoma compression of the pancreatic duct and obstruction of duodenal papilla [12, 14]. Other explana- tions have included the possibility of pancreatic enzyme release during acute or chronic pancreatitis, causing vascular destruction thereby leading hematoma formation [7]. Given the lack of con- sensus, there remains uncertainty in explaining causality between the association of acute pancreatitis and IDH. The management of IDH has evolved since the 1970s, up until which surgical therapy was the mainstay treatment of Figure 1: CT abdomen pelvis showing normal appearing pancreas (red arrow) with no hematoma around. choice [6]. Conservative management in the form of nasogastric Figure 2: EGD revealed a brisk bleeding site in the second portion of the duodenum ~4 cm proximal to the ampula of Vater. Hemostasis achieved with 5 mL epineph- rine and hemostatic clip. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx090/4821286 by Ed 'DeepDyve' Gillespie user on 16 March 2018 A case of acute duodenal intramural hematoma complicated by acute pancreatitis 39 CONSENT Consent for participation was obtained from this patient. GUARANTOR Tagore Sunkara, M.D. REFERENCES 1. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastro- Figure 3: CT abdomen showing edematous appearing pancreas (red arrow) with intestinal bleeding. Ann Intern Med 2010;152:101–13. a large duodenal intramural hematoma at the head of the pancreas (blue 2. Levy J, Khakoo S, Barton R, Vicary R. Fatal injection sclero- arrow). therapy of a bleeding peptic ulcer. Lancet 1991;337:504. 3. Choudari CP, Rajgopal C, Elton RA, Palmer KR. Failures of endoscopic therapy for bleeding peptic ulcer: an analysis of risk factors. Am J Gastroenterol 1994;89:1968–72. 4. Jones WR, Hardin WJ, Davis JT, Hardy JD. Intramural hema- toma of the duodenum: a review of the literature and case report. Ann Surg 1971;4:534–44. 5. Grasshof C, Wolf A, Neuwirth F, Posovszky C. Intramural duodenal haematoma after endoscopic biopsy: case report and review of the literature. Case Rep Gastroenterol 2012;1: 5–14. DOI:10.1159/000336022. 6. Margolis IB, Carnazzo AJ, Finn MP. Intramural hematoma of the duodenum. Am J Surg 1976;132:779–83. 7. Chang CM, Huang HH, How CK. Acute pancreatitis with an intramural duodenal hematoma. Intern Med 2015;54:755–7. Figure 4: CT abdomen showing resolving peri-pancreatic edema (red arrow) and 8. Konstantinidis A, Plurad D, Barmparas G, Inaba K, Lam L, resolving duodenal intramural hematoma (blue arrow). Bukur M, et al. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of tube placement and total parenteral nutrition has shown hema- the cervical spine in evaluable blunt trauma patients: a pro- toma resolution in 3–6 weeks [9]. In cases where conservative spective observational study. J Trauma 2011;71:528–32. management is unsuccessful, IDHs are treated with laparo- doi:10.1097/TA.0b013e3181f8a8e0. scopic surgical drainage or drainage under ultrasound or CT 9. Sugai K, Kajiwara E, Mochizuki Y, Noma E, Makashima J, guidance [15]. Uchimura K, et al. Intramural duodenal hematoma after endoscopic therapy for a bleeding duodenal ulcer in a CONCLUSION patient with liver cirrhosis. Int Med 2005;44:954–7. 10. Fingerhut A, Rouffet F, Eugene C, Fendler JP, Hillion D, IDHs are rare complications in endoscopic management of Ronat R. Nontraumatic intramural hematoma of the duode- gastrointestinal bleeding. They may occur in patients without num; report of 4 cases and rewiew of the literature. underlying blood diseases as in thecaseofour patient, leadingto Digestion 1983;26:231–5. concomitant complications of acute pancreatitis. Conservative 11. Han SJ, Tsai CC, Mo LR, Tseng LJ, Yau MP. Laparoscopic find- management can lead to favorable outcomes. ing and imaging of the iatrogenic duodenal intramural hematoma. Hepatogastroenterology 1997;44:139–42. ACKNOWLEDGMENTS 12. Shiozawa K, Watanabe M, Igarashi Y, Matsukiyo Y, Matsui None. T, Sumino Y. Acute pancreatitis secondary to intramural duodenal hematoma: case report and literature review. CONFLICT OF INTEREST STATEMENT World J Radiol 2010;2:283–8. 13. Dibra A, Kellici S, Çeliku E, Dracini X, Maturo A, Çeliku E. None of the authors have any form of conflicts of interest. Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review. FUNDING G Chir 2015;36:29–31. The authors received no financial support for the research, 14. Touloukian RJ. Protocol for the non operative treatment of authorship and/or publication of this article. obstructing intramural duodenal hematoma during child- hood. Am J Surg 1983;145:330–4. ETHICAL APPROVAL 15. Nolan GJ, Bendinelli C, Gani J. Laparoscopic drainage of an This case report was approved by the institute’s Institutional intramural duodenal haematoma; a novel technique and Review Board as per its policy. review of the literature. World J Emerg Surg 2011;6:42. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx090/4821286 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Oxford Medical Case Reports Oxford University Press

Acute duodenal intramural hematoma complicated by acute pancreatitis—a rare complication of endoscopic epinephrine injection therapy

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Abstract

Intramural duodenal hematoma (IDH) is a rare complication in endoscopic management of ulcer hemorrhage. Usually noted in cases of blunt abdominal trauma, non-traumatic IDHs have been reported in individuals on anticoagulation, with blood disorders, pancreatic diseases and in endoscopic procedures such as biopsy, sclerotherapy and argon plasma coagulation. Patients may be asymptomatic or present with acute blood loss anemia, abdominal pain or vomiting. We report a case of an 83- year-old man with melena and syncope who underwent endoscopy for bleeding ulcer control and subsequently developed acute pancreatitis due to an acute IDH. Computed tomography (CT) scan confirms the diagnosis. Most cases are conservatively managed however when unsuccessful, laparoscopic surgical drainage or ultrasound or CT guided drainage can be performed. and in endoscopic procedures such as biopsy, sclerotherapy INTRODUCTION and argon plasma coagulation [5]. We report a case of an 83- Endoscopic modalities for hemostasis in active gastrointestinal year-old man with melena and syncope who underwent bleeding have evolved over the years. Their effectiveness has endoscopy for bleeding ulcer control and subsequently devel- now made endoscopic management the treatment of choice in oped acute pancreatitis due to an acute IDH. We report on the active ulcer hemorrhage [1]. Sclerotherapy is a safe and effective clinical presentation, and discuss treatment and management modality of hemostasis in bleeding ulcers however there may of this complication. exist some serious associated complications [2]. These complica- tions include mucosal perforation, and ulceration, vessel throm- CASE REPORT bosis and bleeding culminating in serious adverse events [2, 3]. Intramural duodenal hematoma (IDH) is a rare complication An 83-year-old man with medical history of hypertension, dia- in endoscopic treatment of ulcer bleeding. IDHs are usually found betes mellitus type 2, Alzheimer’s dementia and chronic consti- in casesofblunt abdominal trauma[4]. However, non-traumatic pation, presented with dizziness and lightheadedness. He also hematomas have been reported in patients on anticoagulation, reported melena of 5 days duration, which was associated with individuals with underlying blood disorders, pancreatic diseases mild epigastric pain. Physical examination revealed an elderly Received: September 30, 2017. Revised: October 30, 2017. Accepted: November 10, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx090/4821286 by Ed 'DeepDyve' Gillespie user on 16 March 2018 38 E. Ofori et al. male in no acute distress. Abdominal examination was unre- associated intra-peritoneal and extra-peritoneal hematoma markable. Laboratory findings noted hemoglobin 12.3 g/dL, plate- (Fig. 4). Patient’s hemoglobin subsequently improved to 10.1 g/dL let count 239, lipase 28 U/L and INR of 1.1. Further questioning without further PRBC transfusions. Patient was subsequently dis- revealed, he had undergone an esophagogastroduodenoscopy charged home to follow up in the clinic. (EGD) at an outside institution ~2 weeks prior for abdominal pain and he was unsure of the findings. Computed tomography (CT) DISCUSSION scan of abdomen showed uniform mural thickening of gastric IDHs are rare complications in endoscopic management of antrum, and normal appearing pancreas (Fig. 1). Patient’sdizzi- gastrointestinal bleeding. IDHs are however common in cases ness persisted, and hemoglobin dropped to 9.0 over the next 24 h. of blunt abdominal trauma with over half cases occurring in An urgent EGD revealed patchy erythematous gastropathy, and a children under age 15 [4, 6]. IDHs are commonly found in the briskly bleeding site noted in the second portion of the duodenum second and third portions of the duodenum [7]. The close prox- ~4 cm proximal to the ampula of Vater. The mucosa was edema- imity of the second and the third portions of the duodenum to tous but without discernable ulcer (Fig. 2). Hemostasis was the posterior vertebral bodies, coupled with their high sub- achieved with application of 5 mL of 1:10 000 epinephrine injec- mucosal vascularity and fixation by the peritoneum predis- tion and placement of a hemostatic clip. poses these segments of the duodenum to injury including Over the next day, the patient reported worsening epigastric intramural hematomas [8]. Non-traumatic cases of intramural pain and tenderness associated with non-bilious non-bloody hematomas have been reported, usually in patients on anticoa- emesis. Lipase returned elevated at 1235 U/L. He was initiated on gulation, individuals with underlying blood disorders, pancre- intravenous hydration with lactate ringers and was kept nothing atic diseases and in endoscopic procedures such as biopsy, by mouth. CT scan of abdomen showed an ill-defined, ovoid het- sclerotherapy and argon plasma coagulation [5]. erogeneous hyper attenuating structure distal to the hemostatic IDH presents in a variety of ways. Patients may present with clip, expanding the second portion of the duodenum and meas- 2 acute blood loss anemia, abdominal pain, vomiting or may even uring 5.5 × 3.8 cm , most likely representing an intramural hema- be asymptomatic. Very few (<30) cases of IDH after biopsy or toma along with peri-pancreatic edema representing acute sclerotherapy have been reported in the literature to our knowl- pancreatitis (Fig. 3). Hemoglobin trended down to 7.3 g/dL which edge [9]. Most of these patients with IDH after hemostatic ther- responded appropriately with the transfusion of a unit of packed apy had underlying coagulopathy, thrombocytopenia and/or red blood cell (PRBC). Abdominal pain and tenderness resolved liver cirrhosis [4, 7, 9–12]. Dibra et al. [13] however reported a over the subsequent 2 days. A repeat CT scan of abdomen case of IDH after submucosal epinephrine therapy for duodenal showed an interval decrease in size of the IDH and also the bleeding ulcer in a patient without apparent underlying disease. Additionally, all the cases of IDH had a common variable of epi- nephrine injection therapy performed while some had an added combination of ethanolamine injections or hemostatic clipping. Some cases of IDH had an associated acute pancreatitis, theo- rized to be likely due to compression of the ampulla of Vater by the hematoma [14]. Our patient has a similar associated acute pancreatitis but without any known underlying coagulopathy or cirrhosis. The development of acute pancreatitis in cases of IDH has been attributed to hematoma compression of the pancreatic duct and obstruction of duodenal papilla [12, 14]. Other explana- tions have included the possibility of pancreatic enzyme release during acute or chronic pancreatitis, causing vascular destruction thereby leading hematoma formation [7]. Given the lack of con- sensus, there remains uncertainty in explaining causality between the association of acute pancreatitis and IDH. The management of IDH has evolved since the 1970s, up until which surgical therapy was the mainstay treatment of Figure 1: CT abdomen pelvis showing normal appearing pancreas (red arrow) with no hematoma around. choice [6]. Conservative management in the form of nasogastric Figure 2: EGD revealed a brisk bleeding site in the second portion of the duodenum ~4 cm proximal to the ampula of Vater. Hemostasis achieved with 5 mL epineph- rine and hemostatic clip. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx090/4821286 by Ed 'DeepDyve' Gillespie user on 16 March 2018 A case of acute duodenal intramural hematoma complicated by acute pancreatitis 39 CONSENT Consent for participation was obtained from this patient. GUARANTOR Tagore Sunkara, M.D. REFERENCES 1. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastro- Figure 3: CT abdomen showing edematous appearing pancreas (red arrow) with intestinal bleeding. Ann Intern Med 2010;152:101–13. a large duodenal intramural hematoma at the head of the pancreas (blue 2. Levy J, Khakoo S, Barton R, Vicary R. Fatal injection sclero- arrow). therapy of a bleeding peptic ulcer. Lancet 1991;337:504. 3. Choudari CP, Rajgopal C, Elton RA, Palmer KR. Failures of endoscopic therapy for bleeding peptic ulcer: an analysis of risk factors. Am J Gastroenterol 1994;89:1968–72. 4. Jones WR, Hardin WJ, Davis JT, Hardy JD. Intramural hema- toma of the duodenum: a review of the literature and case report. Ann Surg 1971;4:534–44. 5. Grasshof C, Wolf A, Neuwirth F, Posovszky C. Intramural duodenal haematoma after endoscopic biopsy: case report and review of the literature. Case Rep Gastroenterol 2012;1: 5–14. DOI:10.1159/000336022. 6. Margolis IB, Carnazzo AJ, Finn MP. Intramural hematoma of the duodenum. Am J Surg 1976;132:779–83. 7. Chang CM, Huang HH, How CK. Acute pancreatitis with an intramural duodenal hematoma. Intern Med 2015;54:755–7. Figure 4: CT abdomen showing resolving peri-pancreatic edema (red arrow) and 8. Konstantinidis A, Plurad D, Barmparas G, Inaba K, Lam L, resolving duodenal intramural hematoma (blue arrow). Bukur M, et al. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of tube placement and total parenteral nutrition has shown hema- the cervical spine in evaluable blunt trauma patients: a pro- toma resolution in 3–6 weeks [9]. In cases where conservative spective observational study. J Trauma 2011;71:528–32. management is unsuccessful, IDHs are treated with laparo- doi:10.1097/TA.0b013e3181f8a8e0. scopic surgical drainage or drainage under ultrasound or CT 9. Sugai K, Kajiwara E, Mochizuki Y, Noma E, Makashima J, guidance [15]. Uchimura K, et al. Intramural duodenal hematoma after endoscopic therapy for a bleeding duodenal ulcer in a CONCLUSION patient with liver cirrhosis. Int Med 2005;44:954–7. 10. Fingerhut A, Rouffet F, Eugene C, Fendler JP, Hillion D, IDHs are rare complications in endoscopic management of Ronat R. Nontraumatic intramural hematoma of the duode- gastrointestinal bleeding. They may occur in patients without num; report of 4 cases and rewiew of the literature. underlying blood diseases as in thecaseofour patient, leadingto Digestion 1983;26:231–5. concomitant complications of acute pancreatitis. Conservative 11. Han SJ, Tsai CC, Mo LR, Tseng LJ, Yau MP. Laparoscopic find- management can lead to favorable outcomes. ing and imaging of the iatrogenic duodenal intramural hematoma. Hepatogastroenterology 1997;44:139–42. ACKNOWLEDGMENTS 12. Shiozawa K, Watanabe M, Igarashi Y, Matsukiyo Y, Matsui None. T, Sumino Y. Acute pancreatitis secondary to intramural duodenal hematoma: case report and literature review. CONFLICT OF INTEREST STATEMENT World J Radiol 2010;2:283–8. 13. Dibra A, Kellici S, Çeliku E, Dracini X, Maturo A, Çeliku E. None of the authors have any form of conflicts of interest. Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review. FUNDING G Chir 2015;36:29–31. The authors received no financial support for the research, 14. Touloukian RJ. Protocol for the non operative treatment of authorship and/or publication of this article. obstructing intramural duodenal hematoma during child- hood. Am J Surg 1983;145:330–4. ETHICAL APPROVAL 15. Nolan GJ, Bendinelli C, Gani J. Laparoscopic drainage of an This case report was approved by the institute’s Institutional intramural duodenal haematoma; a novel technique and Review Board as per its policy. review of the literature. World J Emerg Surg 2011;6:42. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx090/4821286 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Published: Jan 1, 2018

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