Lumen-apposing metal stent for the management of intramural hematoma of the GI tract

GI intramural hematomas are uncommon and usually occur in the esophagus or the duodenum, and in rare cases they occur in the stomach.¹ The most common cause is blunt abdominal trauma; other causes include endoscopic interventions, peptic ulcer disease, and pancreatitis; in very rare cases they can occur spontaneously in patients receiving oral anticoagulants.2, 3 We present the management of 2 cases of gastric and duodenal intramural hematomas by the use of lumen-apposing metal stents (LAMSs).

Patient 1

An 84-year-old man received a diagnosis of gastric intramural hematoma 3 weeks after laparoscopic distal pancreatectomy and splenectomy for a pancreatic tail neuroendocrine tumor. Gastroscopy revealed a large hematoma occupying almost half of the gastric lumen (Fig. 1A). Linear EUS demonstrated a well-defined heterogenous mass (10.3 × 7.45 cm) in the gastric submucosa with intact muscularis propria (Fig. 1B).

Figure 1.

A, Endoscopic view of hematoma. B, Endosonographic view of hematoma.

Although intramural hematomas are usually managed conservatively, because of the severe symptoms in our patient (nausea, vomiting, and abdominal pain), drainage was recommended. The patient was not a surgical candidate, and the decision was made to perform EUS-directed drainage of the hematoma using a LAMS (Video 1, available online at www.VideoGIE.org).

Under EUS guidance, the hematoma was punctured by use of a 20-mm × 10-mm cautery-assisted LAMS, and the first LAMS was deployed. A second 15-mm × 10-mm cautery-assisted LAMS was then deployed adjacent to the first LAMS to optimize drainage (Fig. 2). Contrast material was then injected, and we confirmed that the hematoma was contained and there was no evidence of leakage.

Figure 2.

Endosonographic view of second lumen-apposing metal stent during deployment of the distal flange.

A guidewire was advanced through each LAMS and coiled inside the hematoma cavity under fluoroscopic guidance. A 10F × 5-cm double-pigtail plastic stent was placed over the guidewire (Fig. 3). A low-residue diet was allowed after 24 hours. Follow-up after 1 month showed reduced size of the hematoma, and the stents were left in place for continual drainage.

Figure 3.

Endoscopic view of the proximal and distal lumen-apposing metal stents and double-pigtail stent seen passing into hematoma.

Patient 2

A 54-year-old woman presented with severe abdominal pain, nausea, and vomiting, diagnosed as acute pancreatitis. CT showed acute pancreatitis associated with a large duodenal intramural hematoma with surrounding hemoperitoneum and biliary tract obstruction (Fig. 4).

Figure 4.

Coronal CT image of abdomen and pelvis showing intramural hematoma occupying entire length of the duodenum (arrows).

Gastroscopy revealed an obstructing duodenal hematoma (Fig. 5) that could not be traversed by endoscope. Angiography revealed no active arterial bleeding, and empiric coil embolization of the gastroduodenal artery was performed.

Figure 5.

Endoscopic view of intramural duodenal hematoma.

Initial conservative management failed, and the patient had worsening of nausea and vomiting, with attacks of aspiration. A follow-up CT demonstrated progressive distension of the stomach and esophagus suggestive of gastric outlet obstruction (GOO).

A multidisciplinary team decided to create an EUS-guided gastroenterostomy for relief of GOO (Video 1). Saline solution mixed with contrast material and methylene blue was infused through the gastroscope to distend the small bowel distal to the obstruction under endoscopic and fluoroscopic guidance (Fig. 6). The gastroscope was switched to a linear echoendoscope. An adjacent bowel loop was identified and punctured with a 19-gauge FNA needle. A guidewire was then advanced, and a 15-mm × 10-mm LAMS with electrocautery-enhanced delivery system was used to create a gastrojejunostomy. The patient was advanced to liquid diet after 24 hours. One week later, she was tolerating a low-residue diet, with no abdominal pain.

Figure 6.

Fluoroscopic image during infusion of contrast material with distention of small bowel, distal to obstruction.

A follow-up CT after 4 months demonstrated resolution of the hematoma. The gastroscope easily traversed the duodenum to the proximal jejunum, and the stomach was visualized through the widely patent LAMS lumen (Fig. 7). The LAMS was then removed, with no adverse events.

Figure 7.

A, Endoscopic view of the lumen-apposing metal stent (LAMS) seen from the gastric side. B, Endoscopic view of the LAMS seen from the intestinal side; stomach can be seen through lumen of LAMS.

In conclusion, LAMS placement is safe and effective for the management of gastric or duodenal intramural hematoma, either by direct drainage or by creation of a temporary bypass tract until spontaneous resolution occurs.

Disclosure

Dr Khashab is a consultant for Boston Scientific, Olympus, and Medtronic. All other authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Lumen-apposing metal stents used for the management of intramural hematomas in the stomach and duodenum.