Spontaneous Large Intramural Hematoma in Roux Limb of Gastric Bypass

Abstract

Purpose: Abdominal pain with a significant hematocrit drop may indicate severe GI bleeding. However, if there is no hematemesis, melena or hematochezia, bleeding from other sources must be considered. We describe a previously unreported case of spontaneous intramural bleeding within the Roux limb in a patient with a history of gastric bypass surgery. Methods: A 34 year old woman, 13 days post bone marrow transplant for acute myeloid leukemia, with a history of Roux-en-Y gastric bypass surgery 2 years prior, developed moderate abdominal pain with Hct 28%, WBC 0.03 K/μL and platelets 6 K/μL. Esomeprazole and sucralfate were initiated, which did not relieve the pain. Over the next 3 days, the Hct dropped from 28% to 15%. The patient had more abdominal pain, tachycardia and hypotension. She had nausea, but no vomiting or hematemesis. She had regular bowel movements, no melena or hematochezia. After resuscitation with fluid, blood and platelet transfusions, the patient underwent an abdominal CT scan. Results: On CT scan, there was an extensive intramural hematoma confined within the Roux limb of the gastric bypass with a wall thickness measuring up to 1.7 cm. The abnormality extended from the gastrojejunostomy to within a few centimeters of the jejunojejunostomy. The patient was given blood and platelet transfusions to maintain the Hct at 30% and platelet at 50 K/μL. The bleeding gradually stopped over a week. The patient's symptoms of abdominal pain and nausea resolved. A repeat CT scan one month later demonstrated complete resolution of the intramural hematoma from the Roux limb. Conclusion: Spontaneous intramural small bowel wall hematoma has been reported in patients with excessive anticoagulation or with other risk factors for bleeding. The jejunum is the most common site of the hematoma, followed by the ileum and duodenum. Abdominal CT scan is the diagnostic modality of choice to detect an intramural hematoma. CT scan findings include circumferential or asymmetric wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Accurate diagnosis is crucial because most patients can be treated nonoperatively with a good outcome. Resolution of the hematoma can be seen as early as 1 week after onset. In our case, the risk factor for bleeding was the extremely low platelet count. The patient responded well to conservative management. This is the first reported case of spontaneous intramural bleeding in the entire Roux limb of a gastric bypass.