Intramural haematoma of the duodenum following endoscopic biopsy: an unusual complication of non-therapeutic endoscopy in children.

Abstract

This case report points out the rarity of intramural duodenal haematomas after intestinal biopsy in children and serves as a reminder to paediatric endoscopists to be aware of this complication. A 4-year-old girl with short stature and increased anti-gliadin antibodies and no history of bleeding disorders underwent upper gastrointestinal endoscopy to obtain a small bowel biopsy. Results of laboratory tests performed prior to the procedure showed a normal platelet count, prothrombin time, and activated partial thromboplastin time. Five duodenal biopsy specimens were obtained using endoscopic grasp forceps with no excessive bleeding being observed. Six hours later the patient presented with abdominal pain and bilious vomiting. Physical examination disclosed normal vital signs and diffuse abdominal tenderness. Levels of haemoglobin, haematocrit, amylase and serum electrolytes were normal. Abdominal ultrasound showed a solid and cystic mass in the second and third duodenal portions. An abdominal CT scan was performed and confirmed the presence of an asymmetrical 4·5 cm mass located within the second and third duodenal portions consistent with an intramural haematoma. The patient followed conservative treatment with total parenteral nutrition. Complete resolution of the haematoma was observed on ultrasound examination on day 19. Two days later the patient was discharged from the hospital. The histological investigation of the intestinal biopsy was normal. Three years later the girl remains asymptomatic and without sequelae. In most cases, intramural duodenal haematoma is an entity caused by abdominal trauma and a complication of therapeutic upper gastrointestinal endoscopy. The development of an intramural duodenal haematoma after endoscopic small bowel biopsy has been reported in nine children, some of them being leukaemic patients or bone marrow transplant recipients [1] and in seven children when using capsule biopsy. It is difficult to state the frequency of intramural duodenal haematoma after biopsy; complications of this procedure develop in less than 2% of cases and are usually mild [4]. In our institution we have performed 2,640 intestinal capsule biopsies and 2,797 upper gastrointestinal endoscopies in children. The only one patient who presented with clinical manifestations of an intramural haematoma is the one described in this report. No other serious complications were observed in our population. The cause of the duodenal haematoma in patients with no underlying disease or therapy-altered coagulation is not clear. Some special features of duodenal anatomy have been involved [3]. Two other facts that could increase the likelihood of haematoma occurrence when biopsies are obtained by endoscopy are the greater number of biopsy specimens obtained and the shear injury associated with obtaining deeper portions of biopsy specimens [5]. In order to prevent this complication, Zinelis et al. [6] have suggested obtaining biopsies from the duodenum extending the forceps no more than 2–3 cm from the endoscope. The clinical presentation of intramural duodenal haematoma is similar in almost all cases and includes severe abdominal pain and vomiting, frequently associated with pancreatitis. Diagnosis is confirmed using imaging techniques with ultrasound, CT scan and upper intestinal series being the most frequently used [2]. Once diagnosis is confirmed and intestinal perforation excluded, conservative treatment with nasogastric C. Camarero (&) AE D. Herrera AE F. Olivares AE B. Roldan Servicio de Pediatria, Hospital Ramon y Cajal, Universidad de Alcala, Madrid, Spain E-mail: ccamareros@yahoo.es Tel.: +34-91-3165443 Fax: +34-91-3368417