Intramural Duodenal Hematoma Complicating Endoscopic Biopsy Presenting With Gastric Outlet Obstruction and Acute Pancreatitis

Abstract

Intramural duodenal hematoma (IDH) complicating endoscopic biopsy is rare in adults. It is more commonly seen in children, and in patients with underlying risk factors, such as trauma, coagulopathy, platelet dysfunction, anticoagulant therapy and endoscopic intervention. We describe a patient without underlying risk factors, who developed IDH following endoscopy with biopsies. The patient presented with a gastric outlet obstruction (GOO) and acute pancreatitis, and resolved with conservative therapy. A 28 year-old healthy male presented with epigastric pain radiating to his back, nausea, vomiting (non-bloody, non-bilious), and intractable hiccups few hours after an upper endoscopy. The endoscopy was performed for evaluation of reflux, dysphagia, and weight loss. Endoscopy revealed reflux esophagitis without strictures. Duodenal, gastric and esophageal biopsies were taken using a standard sized biopsy forceps. He denied any recent trauma or alcohol use and had no history of bleeding tendencies, or medication use. Physical examination showed tachycardia, epigastric tenderness, and bowel sounds were present. Stool was negative for occult blood. Laboratory evaluation showed a white blood count of 13,700/mm3, lipase of 10,830 IU/L, and bilirubin of 3.5 mg/dl (predominately direct). Other liver biochemistries were normal. Extensive testing did not reveal any coagulopathy or platelet dysfunction. CT scan of abdomen with oral contrast was remarkable for thickening of the duodenal wall to 5 cm with lack of emptying of contrast beyond the duodenal bulb. Pathology showed normal mucosal biopsies. Nasogastric suction yielded the return of 1.3 liters of non-bilious, non-bloody fluid. Endoscopy performed on day 5 revealed a GOO caused by submucosal duodenal hematomas with compression of the ampulla of vater. No other hematomas were visualized. The patient responded to conservative therapy and was discharged on a general diet on day 7. We describe the rare complication of IDH following upper endoscopy with standard biopsies in an adult without any risk factors. The IDH was severe enough to cause GOO and acute pancreatitis. The pancreatitis was caused by visually observed ampullary compression by the IDH. Our patient responded well to conservative therapy. IDH should be considered in a patient presenting with gastric outlet obstruction and/or acute pancreatitis following an otherwise uneventful upper endoscopy with biopsies.Figure: Gastric outlet obstruction showing oral contrast in the stomach with a cutoff at the duodenal bulb.Figure: IDH compressing ampulla of vater.Figure: IDH occluding duodenal lumen.