Severe Abdominal Pain 2 Days After Endoscopic Treatment

Abstract

Question: A 47-year-old man with a history of decompensated liver cirrhosis was admitted to our hospital owing to the passage of tarry stools for 3 days. The esophagogastroduodenoscopy (EGD) showed a duodenal ulcer with a visible, nonbleeding vessel (Figure A). Endoscopic hemostasis was achieved by clipping the vessel and injection of epinephrine (12 mL, 0.2%; Figure B). Two days later, the patient developed progressive abdominal pain accompanied by nausea, vomiting, and cold sweating. At that time, physical examination revealed tenderness in the epigastric area without muscle rigidity or rebound pain. Laboratory studies revealed anemia (hemoglobin, 9.9 mg/dL), thrombocytopenia (platelets, 34,000/μL), elevated serum bilirubin (9.1 mg/dL), low serum albumin (2.1 g/dL), elevated serum lipase (809 U/L), and prolonged prothrombin time (International Normalized Ratio, 1.68). Noncontrast computed tomography (CT) of the abdomen at the level of second part of duodenum revealed a hyperdense lesion over the duodenum with fat stranding (Figure C). What is your diagnosis? Look on page 1579 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A 47-year-old man presented 2 days after endoscopic hemostasis with progressive abdominal pain with nausea, vomiting, and cold sweating. Abdominal CT revealed a large hematoma (5 × 8 cm) at the second portion of duodenum with fat stranding, without signs of perforation or ischemia (Figure D). Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma (Figure E). Conservative therapy was provided with bowel rest and parenteral nutrition. The patient's clinical condition improved rapidly. The patient tried a liquid diet 6 days later and tolerated it well. Follow-up EGDs performed at 13 days and 1 month later revealed gradual absorption of the intramural hematoma (Figure F, G). Intramural hematoma of the duodenum occurs most often in patients with abdominal trauma, anticoagulant therapy, coagulopathy, pancreatic disease, and endoscopic procedures.1Shiozawa K. Watanabe M. Igarashi Y. et al.Acute pancreatitis secondary to intramural duodenal hematoma: case report and literature review.World J Radiol. 2010; 2: 283-288Crossref PubMed Google Scholar The primary mechanism of action of epinephrine injection therapy is tamponade, resulting from volume effect. It also creates a space for blood accumulation between mucosal and muscle layer. In rare cases, patients develop intramural hematomas at the former bleeding site, 1–3 days after endoscopic injection treatment.2Rohrer 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: 617-621Crossref PubMed Scopus (34) Google Scholar Most patients with intramural hematoma of the duodenum present with symptoms of intestinal obstruction, including abdominal pain, nausea, and vomiting. This diagnosis was based on the typical abdominal CT image, indicating the presence of a high-density duodenal mass. As described herein, EGD can confirm the presence of a submucosal hematoma and is effective in monitoring its resolution. Conservative therapy with bowel rest and parenteral nutrition was the first-line treatment. Most duodenal hematomas resolve spontaneously within 7–21 days.1Shiozawa K. Watanabe M. Igarashi Y. et al.Acute pancreatitis secondary to intramural duodenal hematoma: case report and literature review.World J Radiol. 2010; 2: 283-288Crossref PubMed Google Scholar Rarely is the condition accompanied by pancreatitis, perforation, and peritonitis.3Yen H.H. Chen Y.Y. Duodenal intramural hematoma and delayed perforation: rare but fatal complication of endoscopic therapy for a bleeding duodenal ulcer.Endoscopy. 2009; 41: E119Crossref PubMed Scopus (3) Google Scholar Surgery should be reserved for those cases where conservative therapy fails or that present life-threatening complications.