Abstract
Intramural duodenal haematoma is a rare complication of endoscopic biopsy. Though other causes such as blunt abdominal trauma are more common, it remains a rare problem in paediatric population. In this article, we report a patient who developed intramural duodenal haematoma following an endoscopic biopsy that was performed to look for evidence of gut graft versus host disease.
Keywords: Endoscopy, GI bleeding, Haematology (incl blood transfusion), Paediatric oncology
Background
Intramural duodenal haematoma is a rare complication of upper gastrointestinal endoscopic biopsy. This procedural complication occurs most commonly in patients with leukaemia,1 patients post-haematopoietic stem cell transplantation (HSCT)2 and in patients with coagulation disorders.3
The intramural haematoma usually manifests as intestinal obstruction, acute pancreatitis or jaundice. With high index of suspicion, the diagnosis and treatment are straightforward provided that the patient is managed at a centre where parenteral nutrition service is available.1 2 4–6
Case presentation
A preschool girl underwent HSCT for beta-thalassemia major. On day 31 post-transplant, she developed skin graft versus host disease (GVHD), which was confirmed histologically. She was commenced on oral prednisolone (1 mg/kg/day). Three to 4 days later, she developed profuse watery diarrhoea that was associated with anorexia, nausea and non-bilious non-bloody vomitus. Physical examination revealed a sick-looking child with normal vital signs. She has mild pallor but no jaundice. Her abdominal examination revealed mild tenderness over the epigastric area.
After excluding infectious causes of her symptoms, she underwent oesophagogastroduodenoscopy (EGD) and flexible sigmoidoscopy to look for gut GVHD.
Investigations
Preprocedure coagulation profile was normal (prothrombin time was 12.3 s (9.8–12.0 s), international randomised ratio was 1.14 (09–1.2), activated partial prothrombin time was 32.8 (25.0–36.4) and fibrinogen 1.8 (1.7–3.6)). She received platelet transfusion and her platelet count was 122×109/L (150–450×10⁹/L).
The EGD revealed mild erythema of antral mucosa and moderate erythema and oedema of the first and second parts of the duodenum with fine nodularity of the first part. The sigmoidoscopy showed mild erythema over the rectum with loss of normal vascular pattern over the sigmoid mucosa. Biopsies were taken from stomach, duodenum, rectum and sigmoid with cold forceps for histological examination.
Few hours after the procedure, her platelet count was 130×109/L, but haemoglobin dropped from 94 g/L to 87 g/L.
The following day, the patient developed epigastric pain and bilious vomiting. A contrast-enhanced CT scan demonstrates intramural haematoma of the second part of the duodenum below the level of ampulla of Vater extending to the third part measuring 44.8×18.6 mm (figure 1).
Figure 1.
Axial (A) and coronal (B) CT images of the abdomen show a circumferential mural haematoma involving mainly the second part of the duodenum (white arrows). The head of the pancreas shows normal enhancement at the site of duodenal haematoma (yellow arrow).
Treatment
The patient was managed by nil orally and received total parenteral nutrition for 12 days. Her symptoms improved and liquid diet was introduced after 10 days. Her oral intake improved gradually and she was able to tolerate full feed after 2 weeks.
Outcome and follow-up
The histological examination of the gut mucosa confirmed the diagnosis of gut GVHD. She was managed with intravenous methylprednisolone and her symptoms improved gradually.
Discussion
The duodenum is the widest part of the small intestine, and it has no mesentery. Anatomically, it is divided into four parts: a superior, a descending, a horizontal and an ascending part (figure 2). The first part is located intraperitoneally, while the other parts located retroperitoneally. The anatomical position of the duodenum (retroperitoneal attachment and the lack of a mesentery as well as the close anatomical relation to the spine) as well as rich submucosal blood supply render the duodenum especially the horizontal part more vulnerable for intramural haematoma after blunt abdominal trauma and after endoscopic biopsy.4 7
Figure 2.
A diagram illustrates the four parts of the duodenum. The figure is done by YR.
The intramural duodenal haematoma in children can result from blunt abdominal trauma and rarely after duodenal endoscopic biopsy.4 5 8 There are certain clinical factors that can increase the risk of intramural duodenal haematoma during EGD and duodenal biopsy. These factors include: post-HSCT,2 patients with leukaemia1 and patients on anticoagulant therapy.3 Another technical factor that can precipitate this complication includes injection therapy for peptic ulcers especially in adult patients with severe underlying diseases associated with coagulation disturbances.9
Abdominal pain and vomiting post-duodenal endoscopic biopsy should raise the suspicion of this rare complication, which can occur from days to weeks after the endoscopy but most commonly within the first 48 hours after the procedure.2 Compression of haematoma on the pancreatic duct may result in acute pancreatitis.4 6 Additionally, obstructing the ampulla of Vater can result in conjugated hyperbilirubinaemia.6
Abdominal CT scan is very sensitive in diagnosing intramural haematoma as well as excluding viscus perforation and assessing features of pancreatitis.7 10 Abdominal sonography is helpful during follow-up10 as it is readily available and involves no radiation.
Intramural duodenal haematoma is treated conservatively with nil per mouth, decompression by nasogastric tube and parenteral nutrition.1 2 4–6 Surgical management is usually reserved for patients who fail conservative management. Ultrasound/CT-guided drainage or endoscopic incision and drainage were also reported to be successful.11–13 Valerii et al reported a safe and effective endoscopic procedure for the treatment of intramural duodenal haematoma using Hot AXIOS (lumen-apposing stent). This technique should be done by an expert intervention endoscopist who is experienced in endoscopic ultrasonography and radiological procedures.14
Learning points.
Intramural duodenal haematoma is a rare complication of upper gastrointestinal endoscopy in children.
Risk factors for duodenal haematoma include: post-haematopoietic stem cell transplantation, graft versus host disease, patients with leukaemia or coagulation disturbance.
Patients typically present with abdominal pain and vomiting within 48 hours of post-endoscopy and the diagnosis can be confirmed by abdominal CT.
Management of intramural duodenal haematoma is conservative in most of the cases.
Acknowledgments
Authors acknowledge the patient’s family in consenting for the case report publication.
Footnotes
Contributors: DR, YAR, HAA and YW were involved in study conception and design, data analysis, writing of the initial draft, critical revision of the submitted manuscript and are the guarantors of the article.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication
Parental/guardian consent obtained.
References
- 1.Lipson SA, Perr HA, Koerper MA, et al. Intramural duodenal hematoma after endoscopic biopsy in leukemic patients. Gastrointest Endosc 1996;44:620–3. 10.1016/S0016-5107(96)70024-X [DOI] [PubMed] [Google Scholar]
- 2.Ramakrishna J, Treem WR. Duodenal hematoma as a complication of endoscopic biopsy in pediatric bone marrow transplant recipients. J Pediatr Gastroenterol Nutr 1997;25:426–9. 10.1097/00005176-199710000-00012 [DOI] [PubMed] [Google Scholar]
- 3.Wang J-Y, Ma C-J, Tsai H-L, et al. Intramural duodenal hematoma and hemoperitoneum in anticoagulant therapy following upper gastrointestinal endoscopy. Med Princ Pract 2006;15:453–5. 10.1159/000095493 [DOI] [PubMed] [Google Scholar]
- 4.Karjoo M, Luisiri A, Silberstein M, et al. Duodenal hematoma and acute pancreatitis after upper gastrointestinal endoscopy. Gastrointest Endosc 1994;40:493–5. 10.1016/S0016-5107(94)70219-5 [DOI] [PubMed] [Google Scholar]
- 5.Szajewska H, Albrecht P, Ziolkowski J, et al. Intramural duodenal hematoma: an unusual complication of duodenal biopsy sampling. J Pediatr Gastroenterol Nutr 1993;16:331–3. [PubMed] [Google Scholar]
- 6.Diniz-Santos DR, de Andrade Cairo RC, Braga H, et al. Duodenal hematoma following endoscopic duodenal biopsy: a case report and review of the literature. Can J Gastroenterol 2006;20:39–42. 10.1155/2006/391702 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Jayaraman MV, Mayo-Smith WW, Movson JS, et al. CT of the duodenum: an overlooked segment gets its due. Radiographics 2001;21 Spec No:S147–60. 10.1148/radiographics.21.suppl_1.g01oc01s147 [DOI] [PubMed] [Google Scholar]
- 8.Ghishan FK, Werner M, Vieira P, et al. Intramural duodenal hematoma: an unusual complication of endoscopic small bowel biopsy. Am J Gastroenterol 1987;82:368–70. [PubMed] [Google Scholar]
- 9.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;26:617–21. 10.1055/s-2007-1009050 [DOI] [PubMed] [Google Scholar]
- 10.Hayashi K, Futagawa S, Kozaki S, et al. Ultrasound and CT diagnosis of intramural duodenal hematoma. Pediatr Radiol 1988;18:167–8. 10.1007/BF02387565 [DOI] [PubMed] [Google Scholar]
- 11.Lloyd GM, Sutton CD, Marshall LJ, et al. Case of duodenal haematoma treated with ultrasound guided drainage. ANZ J Surg 2004;74:500–1. 10.1111/j.1445-1433.2004.03045.x [DOI] [PubMed] [Google Scholar]
- 12.Gullotto C, Paulson EK. CT-guided percutaneous drainage of a duodenal hematoma. AJR Am J Roentgenol 2005;184:231–3. 10.2214/ajr.184.1.01840231 [DOI] [PubMed] [Google Scholar]
- 13.Kwon C-I, Ko KH, Kim HY, et al. Bowel obstruction caused by an intramural duodenal hematoma: a case report of endoscopic incision and drainage. J Korean Med Sci 2009;24:179–83. 10.3346/jkms.2009.24.1.179 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Valerii G, Ormando VM, Cellini C, et al. Endoscopic management of intramural spontaneous duodenal hematoma: a case report. World J Gastroenterol 2022;28:2243–7. 10.3748/wjg.v28.i20.2243 [DOI] [PMC free article] [PubMed] [Google Scholar]