Submucosal Hematoma Research Articles

Validation of a New Endoscopic Technique to Assess Acid Output in Zollinger–Ellison Syndrome

To safely manage the hypersecretory state in patients with Zollinger-Ellison syndrome, both upper endoscopy and gastric analysis are required to titrate optimal medical therapy. Conventional gastric analysis requires more than 1 hour to perform and results in significant patient dissatisfaction. In this study, we have validated endoscopic gastric analysis as a novel technique that can effectively replace conventional gastric analysis. In a prospective, cross-over study, 12 patients with Zollinger-Ellison syndrome underwent gastric analysis, first by the conventional method and then by an endoscopic technique performed on the same day. Acid concentration was determined by titration, volume output was recorded, and acid output was calculated using standard methodologies and formulas. Agreement was assessed following the Bland-Altman method. To assess repeatability, both techniques were repeated on the same day in a subset of patients. Excellent agreement was reported between acid output (95% limits of agreement, -1.27 to 1.61 mEq/h) and acid concentration (95% limits of agreement, -0.01 to 0.01 mEq/mL), although poor agreement was observed between volume output measured. Endoscopic gastric analysis showed greater reproducibility regarding acid and volume output measured. We introduce a new, rapid, reproducible, and accurate endoscopic technique to measure acid output in patients with Zollinger-Ellison syndrome who require both annual endoscopy and gastric analysis. The data presented here suggest that endoscopic gastric analysis would be equally effective in determining acid output in other hypersecretory states. Additional analysis of cost effectiveness is needed to evaluate its use as a screening tool in select populations.

Inflammatory Polyps: A Cause of Late Bleeding in Stapled Hemorrhoidectomy

Stapled hemorrhoidectomy has become a popular treatment of hemorrhoids, mainly because of the benefits of greatly reduced postoperative pain. However, complications unique to the new procedure have been reported. This study was designed to review our series of 82 patients with a focus on complications, with particular focus on late bleeding caused by inflammatory polyps at the staple line. A review of 82 patients who underwent stapled hemorrhoidectomy was conducted. Indications included bleeding in 29 patients, prolapse in 19, combined bleeding and prolapse in 31, and pain in 3. The procedure was performed in an outpatient setting with the Ethicon ILS 33 stapler in the standard fashion. Late bleeding as a result of inflammatory polyps was encountered in nine patients (11 percent). Bleeding was mild, and all cases resolved after excision of the polyps. Other complications occurred with the following frequency: urinary retention (4.9 percent), submucosal hematoma (2.4 percent), early bleeding (1.2 percent), recurrent hemorrhoids (2.4 percent), thrombosed external hemorrhoids (2.4 percent), and fecal urgency (3.7 percent). Bleeding from inflammatory polyps occurs in a significant number of patients undergoing stapled hemorrhoidectomy. Mild bleeding several weeks or months after the procedure should prompt a search for inflammatory polyps at the staple line. Simple excision of the polyps was adequate treatment and has not resulted in rebleeding.

Nonstrangulating small colon obstruction caused by a submucosal haematoma

Nonstrangulating small colon obstruction caused by a submucosal haematoma

Potential causes and alternate methods for diagnosis and treatment of small colon submucosal haematoma: can we extrapolate from human patients?

Potential causes and alternate methods for diagnosis and treatment of small colon submucosal haematoma: can we extrapolate from human patients?

Esophageal submucosal hematoma: a case report and review of the literature

The patient was a 75-year-old man. Under a diagnosis of angina pectoris, he was being treated with aspirin and ticlopidine hydrochloride at a local clinic. Severe postprandial pharyngeal/thoracic pain and hematemesis occurred. Upper digestive tract endoscopy revealed an extensive submucosal hematoma involving the esophageal orifice and cardia. Computed tomography (CT) scan did not show aortic dissociation or mediastinal emphysema. Antiplatelet therapy was discontinued, and follow-up was continued by fasting and conservative treatment with an H2-blocker. Ten days after onset, endoscopy showed the disappearance of the hematoma, and ingestion was started. Twenty-two days after onset, endoscopy revealed regeneration and cicatrization of the esophageal mucosa. In a detailed examination of heart diseases, angina pectoris was ruled out; therefore, antiplatelet therapy was discontinued. There has been no recurrent esophageal submucosal hematoma for 4 years of follow-up.

抗凝固剤内服中に発症した尿管壁内血腫の1例

Intraluminal ureteral hematoma is a rare disease and only a few cases have been previously described. We report a case of intraluminal ureteral hematoma induced by anticoagulant therapy. A 65-year old man having the oral anticoagulant therapy for prevention of secondary thrombolism following atrial fibrillation was referred to us for gross hematuria. Ultrasound sonography (US) revealed right renal mild wide pelvis. Computed tomography (CT) showed the right ureteral submucosal hematoma. This ureteral hematoma penetrated the ureteral mucosa and caused macrohematuria. The patient had been anticoagulated on Warfarin with Bucolome for 18 days, so the prothrombin times (PT) was found to be excessively prolonged beyond the normal therapeutic range. The oral anticoagulation was stopped and intravenous Vitamin K2 was given, so PT was normalized. Though estimate hemorrhage quantity reached 1,200 ml, we had no blood transfusion. The hematoma was completely diminished 4 months later, no reccurence has been occurred. Bucolome has especially pharmacokinetic positive interaction to Warfarin, so we must check PT-INR frequently.

Complications après anopexie circulaire pour cure d’hémorroïdes : résultats à long terme d’une série de 140 malades et analyse de la littérature

Aim. – The aim of this study was to determine the results and the complications of the treatment of hemorrhoids with circular stapler with a follow-up of 18 months, and to review the complications in the literature. Methods. – From April 1998 to August 1999, 140 patients (83 males and 57 females) with an average age of 43.8 years (range: 19–83 years) underwent haemorrhoidectomy using a circular stapler in three university hospital centers. The degree of hemorrhoids has been classified: three cases of degree II, 97 cases of degree III, and 40 cases of degree IV. All the patients were prospectively evaluated at two weeks, two and 18 months after surgery. Results. – The average length of the operation was 18 minutes (range: 8–60 minutes). Mean hospital stay was 36 hours (range: 8–72 hours). There was no intraoperative complication. There was no mortality. The postoperative complication rate was 7.8% ( N =11): there were five cases of bleeding that two complicated by a submucosal hematoma (one was infected and needed a rectotomy on day 21), two cases of urinary retention, and two cases of external hemorrhoid thrombosis. The bleeding occurred in the 12 hours after surgery except for one patient with antivitamin K whith presented a secondary bleeding on day 16. At 18 months, five patients presented a moderate asymptomatic stricture dilated on digital examination. Two patients complained of persistent skin tags. Neither functional trouble nor incontinence to gas, liquids, or solids was presented. With a mean follow-up of 40 months, 90% ( N =112) of the patients were fully satisfied. Conclusions. – Treatment of hemorrhoids with circular stapler appears to be effective with 96% of patients fully satisfied at 18 months. The morbidity rate was low, and no higher than the diathermy excision hemorrhoidectomy. The results are directly dependent on the practice that required a learning, and not on the technique itself.

Endoscopic Sonographically Guided Fine-Needle Aspiration Yield in Submucosal Tumors of the Gastrointestinal Tract

To study the yield of endoscopic ultrasonographically guided fine-needle aspiration cytologic examination in the diagnosis of submucosal masses. From 1999 to 2003, 10 patients underwent ultrasonographically guided fine-needle aspiration for the cytologic diagnosis of submucosal masses in our institution. The endoscopic ultrasonography records and the cytology database were consulted, and the reports were analyzed, as were slide material and the technical aspects related to these procedures. All procedures were performed under conscious sedation and cardiorespiratory monitoring on an outpatient basis. Ten patients (4 men and 6 women; mean age, 60.8 years) were studied. Eight lesions were located in the stomach, and 2 were located in the esophagus, with a mean diameter of 3.3 cm. An experienced cytopathologist was present on-site during all procedures for assessment of adequacy and preliminary cytologic examination. Cytologic diagnoses were obtained in 8 cases as follows: 6 gastrointestinal stromal tumors, 1 organizing submucosal hematoma, and 1 low-grade mucosa-associated lymphoid tissue-associated lymphoma. Two cases consisted of scant gastric epithelium only and were considered nondiagnostic. The cytologic diagnoses guided further clinical treatment. Ultrasonographically guided fine-needle aspiration with cytopathologic analysis has a high accuracy rate (80%) for diagnosing submucosal lesions. These findings potentially affect clinical decision making.

Usefulness of EMR with an oblique aspiration mucosectomy device compared with strip biopsy in patients with superficial esophageal cancer

Background EMR is now widely accepted as a treatment option for superficial esophageal cancer. Endoscopic oblique aspiration mucosectomy with an oblique aspiration mucosectomy device was performed, and the results were compared retrospectively with those of conventional strip biopsy. Methods Strip biopsy (April 1991 through October 1999) or endoscopic oblique aspiration mucosectomy (November 1999 through December 2002) was performed in a consecutive series of patients with superficial esophageal squamous-cell carcinoma. Variables assessed were size of resection specimens, rate of complete resection, and complications. Results Of the consecutive series of 66 patients with superficial esophageal cancer, 27 underwent strip biopsy and 39 had endoscopic oblique aspiration mucosectomy. The two groups were similar with respect to age, gender, and lesion macroscopic appearance. The endoscopic oblique aspiration mucosectomy group had a significantly greater mean depth of tumor invasion and had significantly more large lesions vs. the strip biopsy group. The mean longest diameter of resection specimens was significantly greater with endoscopic oblique aspiration mucosectomy (23.9 [5.2] mm) than with strip biopsy (15.2 [4.9] mm) ( p<0.001). The en bloc resection rate was 33.3% (9/27) in the strip biopsy group and 46.2% (18/39) in the endoscopic oblique aspiration mucosectomy group ( p = 0.322). Despite larger lesion size in the endoscopic oblique aspiration mucosectomy group, the complete resection rate was similar between the strip biopsy (70.4%) and endoscopic oblique aspiration mucosectomy (74.4%) groups ( p = 0.783). The complete resection rate for lesions 30 mm or greater in diameter was slightly but not significantly higher in the endoscopic oblique aspiration mucosectomy group (84.4%) compared with the strip biopsy group (70.4%) ( p > 0.999). With respect to complications, the rates of bleeding and submucosal hematoma were similar. Esophageal stenosis occurred after the procedure in 3 patients in the endoscopic oblique aspiration mucosectomy group. All were managed by endoscopic dilation, and symptoms improved. Conclusions Endoscopic oblique aspiration mucosectomy is safe and effective for the treatment of superficial esophageal cancer.

Huge submucosal hematoma of the stomach after accidental removal of the PErcutaneous endoscopic gastrostomy tube

We report a case of massive hemorrhage and aspiration pneumonia as complications of percutaneous endoscopic gastrostomy (PEG). Three months after insertion of a PEG tube, the patient accidentally pulled out the tube by himself. After the accident, the patient experienced hematemesis, which caused aspiration pneumonia. The button-type tube was reinserted into the PEG fistula for hemostasis. The bleeding stopped temporarily; however, 21 days later, the patient relapsed into a condition of massive PEG site bleeding and hematemesis. He was transferred to our hospital, Kuniyoshi Hospital, to control the bleeding and aspiration pneumonia. Endoscopy revealed a sliding type of large hiatal hernia and a huge submucosal hematoma with an ulceration at the lower part of the gastric body. Emergency surgery including local gastrectomy, gastrostomy, jejunostomy and tracheostomy were helpful to treat these complications. Endoscopists should be aware how to treat these complications. One should not hesitate to perform open surgery when other treatments fail.

A case of spontaneous submucosal hematoma

Submucosal hematoma of the esophagus is rare disease. We herein report a case of spontaneous submucosal hematoma of the esophagus. A-74-year old male with vomiting approximately 100ml of blood after vomiting to repeat visited the Metropolitan Bokuto Hospital. Emergent endoscopy revealed a giant hematoma on the wall of the entire esophagus. He was performing the anti-solidification treatment to thrombo-sis, and was considered to be one of the causes of hematoma. An anti-solidification treatment was stopped at the time of hospitalization. Fasting and intravenous hyperalimentation were begun and follow up studies were conducted using endoscopy. In the third endoscopic examination on eight hospital days, the hematoma had disappeared and a deep ulcer was noted. The ulcer became shallow under conservative therapy, and it became scar and there was no constriction of the esophagus in the 4th endoscopic examination on 22 hospital days. From the 34 cases of spontaneous submucosal hematoma inJapan, it was thought that the prognosis of this disease was excellent under conservative therapy also in the patient in an anti-thrombus treatment, or a patient with a bleeding tendency.

Synchronous colon cancers associated with a submucosal hematoma

Synchronous colon cancers associated with a submucosal hematoma

1 P Colonic sub-mucosal haematoma following saline injection for a strip biopsy polypectomy

1 P Colonic sub-mucosal haematoma following saline injection for a strip biopsy polypectomy

A case of Esophageal submucosal dissection

A 75 year-old female was admitted to our hospital complaining of hematemesis and chest pain after food ingestion. Urgent upper-endoscopy revealed the existence of esophageal submucosal hematoma with dissection extending the posterior wall of the entire esophagus. The esophagograms showed so-called double barrelled esophagus. The CT scan of the chest revealed thickening of the esophageal wall and air appearance beside the true esophageal lumen. Fasting and intravenous hyperalimentation were prescribed on admission. Her condition and the endoscopic findings improved immediately. The endoscopic examination on the 22 day of hospitalization showed that the elevated lesion had disappeared and the esophagograms also improved. She started to take meal, however, the symptoms did not relapse. Generally speaking, the prognosis of this disease is excellent under the conservative therapy. In this case, it seemed that a sudden rise of the internal pressure of the esophagus injured blood vessels in the submucosa and caused the submucosal hematoma.

Aortoesophageal Fistula: Recognition and Diagnosis in the Emergency Department

An aortoesophageal fistula is a life-threatening cause of gastrointestinal bleeding where an abnormal communication between the esophagus and the aorta may result from a thoracic aortic aneurysm, foreign body ingestion, esophageal malignancy, or postoperative complications. The diagnosis can be made on the basis of clinical findings alone. Classic patients present with the triad of midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval (Chiari’s triad). The identification of massive upper gastrointestinal hemorrhage that is bright red and arterial in nature is characteristic. Most diagnostic tests have significant individual limitations. Endoscopy of the upper gastrointestinal tract should exclude alternative bleeding sources and may show a submucosal hematoma. Aortography may be useful during active hemorrhage to demonstrate the fistula, but results of aortography may be negative during the symptom-free interval. Dynamic computed tomography may be a more rapid alternative. For patients who are in stable condition after the sentinel hemorrhage, a confirmatory test is reasonable. Patients in unstable condition should undergo immediate surgery. Survival is now possible with rapid surgical intervention. [Heckstall RL, Hollander JE: Aortoesophageal fistula: Recognition and diagnosis in the emergency department. Ann Emerg Med October 1998;32:502-505.]

Nose Surgery (Rhinoplasty) Without External Immobilization and Without Internal Packing: A Review of 812 Cases

In a review of 812 cases of rhinoplasty, none of our patients had early bone or septal displacement; swelling, bruising, and pain were almost nonexistent. This confirms that an external splint would not have been of any benefit in these cases. Packing should help prevent epistaxis, synechiae, and early bone and septal displacement. Not using any packing, we have not encountered these complications. Besides, we have not seen a single submucosal hematoma or a septal necrosis. Therefore, we doubt the value of packing in our patients. The inconveniences and complications of external splints and internal packing are described. Early postoperative photographs show the reduced swelling and bruising, and late photographs show the final results. Difficult primary and secondary rhinoplasty cases are demonstrated.

1％Aethoxysklerolを用いた食道静脈瘤硬化療法によって形成された粘膜下血腫に対し，クリッピングが著効した1例

A 64-year-old woman was diagnosed as having liver cirrhosis by biopsy 3 years previously. Esophageal varices were noted the previous year. She was treated by endoscopic variceal ligation (EVL) and EIS, but the varices recurred. Therefore, we performed endscopic injection sclerotherapy ligation (EISL) . EISL was successful and 1 week after EISL, we performed EIS by extra-vascular injection of 4ml of Aethoxysklerol. At 4 days after EIS, a submucosal hematoma was observed. She was treated by conservative measures, but submucosal hematoma had increased in size at 11 days. So, we tried clipping the surface of the hematoma. The hematoma had disappeared 4 days after clipping, but then a deep ulcer appeared. After one month, the ulcer was completely healed and the appearance of the varices was F0. We reported one successful case of clipping to treat submucosal hematoma after EIS.

A CASE OF INTRAMURAL HEMATOMA OF THE SMALL INTESTINE INDUCED BY ANTICOAGULANTS

We reported a rare case of intramural hematoma of the small intestine induced by anticoagulants therapy, and discuss the differential diagnosis with resembling mesenteric artery occlusion. A 70-year-old man was admitted to the hospital because of abdominal pain and vomiting. He had a history of arteriosclerosis obliterans and been treated with anticoagulant agents including warfarin. Physical examination revealed abdominal tenderness and paritoneal signs. laboratory test showed leukocytosis and depressed coagulability. He underwent an emergency laparotomy under a preoperative diagnosis of intestinal necrosis due to mesenteric artery occlusion. A proximal part of the jejunum, about 60cm in length, was discolored and markedly thickened, and these findings were similar to those of intestinal necrosis. Fresh hemoperitoneum was also noted. Partial resection of the jejunum was performed. During the operation, airway bleeding and hematuria were observed. Histopathological examination disclosed a marked submucosal hematoma with intact mucosa and muscle layer, and led to the final diagnosis of intramural hematoma of the jejunum. Preoperative enhanced CT had demonstrated a “three-layer donuts appearance”, and it seemed a characteristic findings of intramural hematoma of the small intestine.

骨髄異形成症候群を基礎疾患としたＳ状結腸壁内血腫・腸壊死の１例

This is a report of a case of intramural hematoma and necrosis of the sigmoid colon in a patient with myelodysplastic syndrome (MDS). The patient is a 77-year-old man diagnosed with MDS ten months prior to the development of this condition. He consulted a physician because of left lower abdominal pain and was referred to us with a tentative diagnosis of impending rupture of an abdominal aortic aneurysm. He had anemia, leukocytosis and thrombocytopenia. CT scan showed an abdominal aortic aneurysm and an enlarged sigmoid colon. The patient received platelet transfusions and was operated on 30 hours after the onset of symptoms. A 20-cm length of sigmoid colon was found to be was necrotic, and the affected segment of bowel was resected with sufficient margins and end-to-end anastomosis was performed. A submucosal hematoma was discovered, and a diagnosis of non-traumatic intramural hematoma and necrosis of the sigmoid colon was made. The patient resumed oral food intake uneventfully and was discharged 155 days after the operation. CT scanning was helpful in establishing the diagnosis of a rare intramural hematoma of the colon in our patient. MDS was suspected to have played a major role in the pathogenesis.

Acute frontal sinus barotrauma

A 25-year-old man presented to the emergency department with an acute onset of frontal sinus pain during descent on a commercial airliner. There was no history of recent upper respiratory infection, sinus infection, or chronic allergic rhinitis. Sinus radiographs demonstrated a left frontal sinus submucosal hematoma. Symptoms improved within 24 hours with systemic and topical decongestants/vasoconstrictors and a nonsteroidal antiinflammatory agent. He was asymptomatic at 1 week postinjury.