2173 Successful Endoscopic Drainage of Intraperitoneal Hematoma Using Lumen Opposing Fully Covered Metal Stent and Intracavitatory Thrombolytics

Abstract

INTRODUCTION: Incompletely drained intraperitoneal collections represent a therapeutic challenge. Interventional radiologists and surgeons have employed adjunctive intracavitary fibrinolytic agents to break down collections, however it has not been employed endoscopically to the best of our knowledge. We present a case of an intraperitoneal hematoma in a patient which was successfully drained endoscopically using thrombolytics. CASE DESCRIPTION/METHODS: A 16 year old male with past medical history of idiopathic thrombocytopenic purpura presented to our hospital with complains of left upper quadrant abdominal pain, radiating to the back for four days prior to the presentation. He also reported a blunt trauma to the upper abdomen two months prior to the presentation. Abdominal examination revealed tenderness to palpation in LUQ, with no guarding or rigidity and normal bowel sounds. Laboratory values at the time of presentation were within normal limits. Upper endoscopy and Colonoscopy were performed. Upper endoscopy revealed mild erosive gastritis. Colonoscopy was normal. He underwent Computed Tomography (CT) of abdomen and pelvis with contrast, revealing a 5 × 6 × 6.7 cm mass likely a hematoma abutting the spleen, pancreas and left kidneys. Hospital course complicated by fever and leukocytosis. Transgastric drainage of hematoma was performed by Endoscopic Ultrasound (EUS) using fully covered lumen opposing 1.5 cm wide and 1 cm long stent placement with initial drainage of purulent material. Two additional EGDs needed over subsequent two weeks to address one episode of fever with unchanged collection size and thick internal debris. First washout was done with 2000cc of Normal Saline, 500cc of Gentamicin, and 4 mg of Alteplase. During the second washout, we instilled 4 mg of Alteplase and 5 mg DNAse in 60 ml saline with occlusion technique for 10 minutes and subsequent drainage. Patient was discharged and was symptom free. CT scan performed at 8 weeks post placement showed complete drainage of hematoma and stent was removed. Patient is pain free and doing well after that. DISCUSSION: The use of fibrinolytics in endoscopic drainage of intraabdominal effusions has not been explored. In our case the use of fibrinolytics facilitated the dissolution of thick internal debris resulting in complete resolution of the collection. In conclusion, adjunctive use of tPA and DNAse along with EUS guided drainage appears to be safe and effective to dissolve thick internal debris avoiding the need for surgical intervention.