Submucosal Hematoma Research Articles

Severe gastroparesis complicated by gastric perforation caused by lightchain amyloidosis.

AL-Amyloidosis is a rare systemic disease that can occur in patients with monoclonal gammopathy or multiple myeloma. As multiple organs may be affected by deposition of amyloid fibrils, the clinical presentation varies considerably, and the diagnostic process may be challenging.We report on a 59-year-old female who suffered from gastroesophageal reflux symptoms, nausea, epigastric pain, and meteorism over several years. Repeated upper GI endoscopies including biopsies and CT scans were unremarkable except for unspecific enlargement of mesenterial lymph nodes.A few weeks after a surgical hiatal hernia repair with fundoplication, the patient developed massive distension of the stomach and the proximal duodenum resulting in gastric perforation. Histopathological staining of gastric biopsies and mesenterial lymph nodes using hematoxylin and eosin was unremarkable. Because of endoscopic findings (submucosal hematomas, and ulcerations) and the unexplained severe motility disorder, histopathological staining was performed using Congo red. Extensive amyloid deposits were seen. Further workup confirmed AL amyloidosis caused by monoclonal gammopathy. Specific oncological treatment was started.The rare differential diagnosis of amyloidosis should be taken into account in patients with unexplained motility disorders, unspecific gastrointestinal symptoms, and abdominal lymphadenopathy. In the presented case, delayed diagnosis of AL amyloidosis in the gastrointestinal tract led to severe gastroparesis resulting in gastric perforation. Specific histopathologic staining can confirm the diagnosis.

A case of esophagogastric submucosal hematoma with hemorrhagic shock.

A 70-year-old woman had been taking steroids for granulomatosis with polyangiitis since the age of 60years and warfarin for deep vein thrombosis since the age of 63years. She was admitted to the emergency unit of our hospital in a shock vital with complaints of sudden onset of epigastralgia, nausea, and melena. Laboratory data revealed anemia, hypoalbuminemia, and coagulation disorders. Enhanced computed tomography demonstrated extravasation in the middle part of the gastric body in an extensive submucosal hematoma extending from the upper esophagus to the entire gastric body. Emergency esophagogastroduodenoscopy depicted a large submucosal hematoma and a large amount of fresh blood in the stomach; however, active bleeding was not identified. Two sessions of interventional radiology treatment in the emergency department, followed by an intensive care, successfully treated the patient without any complications. We report a unique case of a sudden-onset esophagogastric submucosal hematoma with hemorrhagic shock requiring an intensive care and interventional radiology treatment. In this case, the extensive warfarization and the fragility in vascular and connective tissue components in the submucosa due to the long-term steroid therapy and the granulomatosis with polyangiitis-related alteration might comprehensively cause severe esophagogastric submucosal hematoma even without any apparent triggers.

Spontaneous esophageal submucosal hematoma.

A 57-year-old woman presented to our hospital with chest distension, sore throat and back discomfort beginning the previous day after taking 5 panax notoginseng capsules. She had a history of hypertension for more than 2 years. Physical examination was unremarkable. Blood tests revealed results: A red blood cell count of4.27T/L, a platelet count of 296G/L, a hemoglobin count of 130 g/L (130-175 g/L), and a D-dimer count of0.252 mg/L. Endoscopy showed a longitudinal dark red submucosal hematoma (SH) extending from 20 cm down to 36 cm, with no active bleeding. The next day an enhanced CT of the chest showed uneven thickening of esophageal wall suggestive of intramural esophageal hematoma. A second endoscopy was performed 6 days later, and it showed an esophageal ulcer where the hematoma had been seen at the previous part. The patient was treated with a proton pump inhibitor (PPI) and nutritional support while oral intake was completely prohibited. Her symptoms gradually improved and disappeared. She was discharged one week after the second Upper GI endoscopy when she was able to eat liquid diet. After discharge, she continued the PPI and Kang Fuxin for 2 months. During the 4-month follow up, the symptoms did not recur.

Clinical, Endoscopic, and Histopathologic Observations in Gastrointestinal Amyloidosis.

Amyloidosis is a group of systemic disorders caused by extracellular deposition of misfolded serum proteins. Gastrointestinal (GI) involvement is associated with a higher risk of GI bleeding, especially if mucosal lesions are present. Our study aims to evaluate the frequency of GI manifestations in patients with amyloidosis, to clinically characterize these patients and to describe the endoscopic and histopathologic findings in GI amyloidosis. A retrospective, single-center study of all patients admitted with amyloidosis and GI manifestations was conducted at a German University Hospital between July 2003 and June 2023. Clinical, endoscopic, and histopathological data was retrieved from medical records. Between July 2003 and June 2023, 63 patients with different types of amyloidosis were included into the study. Twenty-three (36,5%) were diagnosed with GI involvement of amyloidosis (60.9% male, median age 62 ± 18.28 years). The distribution of the types of amyloidosis were amyloid light chain (AL) at 52.5%, transthyretin (ATTR) at 21.7%, amyloid A (AA) at 13.0%, and unknown at 18%. Initial GI symptoms were present in 78.3% of the patients and included mainly diarrhea (34.8%), and abdominal pain (30.4%) Affected GI organs were primarily the colon (60,8%) and the stomach (39.1%). Endoscopic findings were ulcerations (47.8%), mucosal inflammation (43.5%), polyps (26.1%), erosions (13.0%), vascular malformation, polypoid protrusion, submucosal hematoma, erythema, metaplasia, and diverticulum. Histopathological findings included vascular wall thickening, (peri-)vascular and interstitial amyloid deposition. Gastrointestinal bleeding occurred in 39.1% of the patients. The mortality rate 5 years after diagnosis was 47.8%. Gastrointestinal amyloidosis can present with multiple symptoms and endoscopic findings, rendering diagnosis a challenge. Of clinical relevance, GI bleeding was a frequent event in our patient cohort. Therefore, clinicians must be aware of GI bleeding as a manifestation of amyloidosis and definite diagnosis should be achieved based on biopsy results.

Submucosal Hematoma of Esophagus Induced by Chewing Betel Nut

Submucosal Hematoma of Esophagus Induced by Chewing Betel Nut

S2430 Sigmoid Submucosal Hematoma: A Complication of Colonoscopy in a Healthy 51-Year-Old

S2430 Sigmoid Submucosal Hematoma: A Complication of Colonoscopy in a Healthy 51-Year-Old

Left gastric artery pseudoaneurysm: a rare presentation of delayed bleeding after peroral endoscopic myotomy for achalasia cardia

A 22-year-old with type I achalasia cardia underwent peroral endoscopic myotomy (POEM) by use of an anterior approach at our center. The patient had an episode of hematemesis 48 hours after the procedure, along with a drop in hemoglobin of 3.5 g/dL. Urgent upper GI endoscopy showed a large submucosal bulge in the esophagus extending into the stomach along the lesser curvature, suggestive of submucosal hematoma (A). CT angiography showed a large submucosal hematoma with a pseudoaneurysm arising from a branch of the left gastric artery (B, white arrow) in relation to the left gastric artery (B, yellow arrow).

A rare cause of post-ESD pain: Submucosal hematoma at the lesion margin

Submucosal hematoma at the margin of the excised lesion after endoscopic submucosal dissection is extremely rare. These patients may experience persistent epigastric pain after the procedure. In this case, report we will discuss about a rare condition.

Gastrointestinal amyloidosis in a patient with smoldering multiple myeloma: A case report

BACKGROUNDSmoldering multiple myeloma (SMM) is an asymptomatic plasma cell proliferative disorder that can progress to multiple myeloma (MM). Amyloidosis (light chain) (AL) is the most common form of systemic amyloidosis. There are few reports of SMM coexisting with AL involving the digestive tract. CASE SUMMARYA 63-year-old woman presented with lower limb edema, abdominal distension, abdominal pain, and hematochezia. Gastroscopy showed gastric retention, gastric angler mucosal coarseness, hyperemia, and mild oozing of blood. Colonoscopy showed hyperemic and edematous mucosa of the distal ascending colon and sigmoid colon with the presence of multiple round and irregular ulcers, submucosal ecchymosis, and hematoma. Gastric and colonic tissue biopsy confirmed the diagnosis of AL by positive Congo red staining. MM was confirmed by bone marrow biopsy and immunohistochemistry. The patient had no hypercalcemia, renal dysfunction, anemia, bone lesions or biomarkers of malignancy defined as plasma cells > 60% in bone marrow. Additionally, no elevated serum free light chain ratio, or presence of bone marrow lesions by magnetic resonance imaging (SLiM criteria) were detected. The patient was finally diagnosed with SMM coexisting with AL. She received chemotherapy and was discharged when the symptoms were relieved. She is doing well at nearly five years of follow up.CONCLUSIONThis case highlights that high index of suspicion is required to diagnose gastrointestinal AL. It should be suspected in elderly patients with endoscopic findings of granular-appearing mucosa, ecchymosis, and submucosal hematoma. Timely diagnosis and appropriate therapy can help to improve the prognosis of these patients.

When hematochezia becomes a red herring.

An 81-year-old male patient presented on the emergency ward for hematochezia, without any other complaints. Rectosigmoidoscopy showed a predominant patchy inflammation of the mucosa with several bluish blebs (submucosal hemorrhage) and small ulcerations. (Figure 1A). Subsequent elective colonoscopy (1) revealed multiple submucosal hematomas and mucosal lacerations throughout the entire colon in between normal mucosa. During the procedure spontaneous mucosal tears occurred. (Figure 1B). Multiple biopsies were taken.

S3169 An Unusual Cause for Persistent Anemia: Gastric Amyloidosis

Introduction: This case highlights an unusual presentation of amyloidosis and multiple myeloma which was discovered during endoscopic and histological evaluation of the gastrointestinal tract for persistent anemia. Thus, it is important to consider these underlying malignancies during work up of anemia with proper biopsies and staining. Case Description/Methods: 67 year old woman with Zenker’s diverticulum and chronic gastrointestinal symptoms attributed to IBS presented for persistent iron deficiency anemia of Hgb 10 and rectal bleeding. A 2 cm sigmoid colon Hamartomatous polyp and a 4 mm cecal tubular adenoma were resected during colonoscopy with normal terminal ileum. While rectal bleeding resolved, surveillance colonoscopy in 6 months showed no residual polyp. Due to persistent anemia despite iron replacement, she underwent an EGD which showed a grossly normal stomach and mild duodenitis. Random biopsies of antrum and duodenum showed acellular pink/amorphic matrix in lamina propria and muscularis mucosa with green birefringence on congo red staining, consistent with amyloid. The patient was referred to hematology/oncology for further work up of amyloidosis. SPEP and immunofixation showed IgA monoclonal gammopathy and free light chain assay revealed 2401.9 mg/L kappa light chains, with a kappa/lamda ratio of 343.13. UPEP showed M spike with positive Bence Jones protein, kappa type. Bone marrow biopsy revealed 13% plasma cells. Patient was diagnosed with amyloid light chain amyloidosis and multiple myeloma and began treatment with systemic chemotherapy. Later in the course, patient had recurrence of rectal bleeding. Repeat colonoscopy was normal, but EGD showed multiple small gastric ulcers which was felt to be the sequelae of gastric amyloidosis. Discussion: Gastric amyloidosis as the presenting pathology of multiple myeloma is rare. Symptoms include abdominal pain, bleeding, motility issues, and malabsorption. Endoscopic findings most commonly show ulcerations, mucosal erosions, and submucosal hematomas. Because these findings are nonspecific, it can be difficult to diagnose unless the clinician has high suspicion for the disease. In our patient’s case, the initial investigation was prompted due to persistent anemia. Unlike the typical mucosal abnormalities seen in gastric amyloidosis, our patient had grossly normal mucosa. Only after biopsies of the stomach and duodenum to rule out H. pylori and celiac disease were performed did we discover the patient had amyloidosis and ultimately multiple myeloma.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

Submucosal esophageal hematomas in a critically ill patient on anticoagulation

Submucosal esophageal hematoma is an uncommon clinical complication of anticoagulation. Current literature is scarce regarding presentation and management in acute submucosal hematomas in critically ill patients. Patients often present with retrosternal chest pain, making the diagnosis challenging due to overlap with common presentations of cardiopulmonary disorders. A high degree of suspicion is necessary in sedated patients. Several factors contribute to its etiology, and diagnosis often requires invasive techniques like endoscopy. However, management is usually supportive and aimed at its underlying cause. This is a case of a 68-year-old female who developed submucosal esophageal hematomas following anticoagulation for subarachnoid hemorrhage-related delayed neurological deficits in the intensive care unit

S2133 Amyloidosis-Associated Gastric Ulceration and Submucosal Hematoma

INTRODUCTION: A 77-year-old woman with a history of atrial fibrillation treated with apixaban presented to the hospital after a presyncopal event and hematemesis. Endoscopic evaluation revealed a large submucosal hematoma, which was initially suspicious for an isolated gastric varix, and 2 large gastric ulcers which biopsy later identified as amyloidosis. CASE DESCRIPTION/METHODS: A 77-year-old woman with a history of atrial fibrillation treated with apixaban presented to the hospital after a presyncopal event. Approximately 12 hours after admission, she was noted to have frank hematemesis, requiring IV fluids, blood, and plasma transfusion. EGD demonstrated copious clotted blood in the gastric fundus and a submucosal lesion which appeared to be an isolated varix in the gastric body. The patient was then transferred to a tertiary care center to be evaluated for endoscopic cyanoacrylate therapy. Upon arrival, she was noted to have intermittent episodes of bradycardia, but otherwise remained stable. She experienced no additional episodes of GI bleeding. Repeat EGD demonstrated 2 large, clean-based gastric ulcers with beefy-red margins. Biopsy later identified these as amyloidosis. No interventions were performed on the gastric lesion initially thought to be a gastric varix. This lesion was likely a submucosal hematoma. The patient was discharged to home in stable condition on twice-daily proton-pump inhibitor therapy. DISCUSSION: Amyloidosis is characterized by the pathologic deposition of proteins throughout the body. Within the GI tract, this deposition increases the frailty of blood vessels, hinders intrinsic peristalsis and decreases the compliance of the gut wall, and may present with varying degrees of upper and lower GI bleeding. Cardiac conduction abnormalities are also associated with amyloidosis. The cornerstone of treatment for acquired amyloidosis is the treatment of the underlying disorder causing elevated amyloid precursors. Uniquely, amyloidosis is also associated with submucosal hematoma. The patient in this case presented with massive upper GI bleeding due to amyloid-induced ulcers, and bleeding from these ulcers was exacerbated by apixaban use. Two unique findings suggesting amyloidosis were unexplained bradycardia and a prominent gastric submucosal hematoma (initially thought to be a gastric varix), both of which are highly associated with amyloidosis. Although the patient was discharged in stable condition, she remains at high risk of morbidity and mortality from this systemic disease.Figure 1.: Large gastric body ulcer with prominent beefy-red margins. Biopsies from ulcer margins showed amyloidosis.Figure 2.: Two large amyloidosis-associated gastric ulcers on opposing walls of the gastric body.Figure 3.: This amyloidosis-associated submucosal hematoma was initially mistaken for a gastric varix.

Importance of second-look endoscopy after per-oral endoscopic myotomy for safe postoperative management.

Per-oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second-look endoscopy (SE) on postoperative day 1 has not been examined. This study aimed to evaluate the findings and need of SE after POEM. This is a single-center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly-detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE. Four-hundred-ninety-seven patients (mean age, 50.3years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE. Second-look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.

Sa1262 A LARGE SINGLE-CENTER STUDY ON THE CLINICAL OUTCOMES OF PER-ORAL ENDOSCOPIC MYOTOMY FOR SIGMOID TYPE 2 ACHALASIA

Per-oral endoscopic myotomy (POEM) has been recognized as a safe and effective minimally-invasive endoscopic treatment for achalasia. Good clinical outcomes have been reported on the application of POEM in straight type achalasia. On the other hand, results of POEM in sigmoid type achalasia, especially sigmoid type 2, are limited. This study aims to report the clinical outcomes of POEM for sigmoid type 2 achalasia. A single-center retrospective study was conducted. A prospectively collected database of 2000 patients who underwent POEM in Showa University between September 2008 to June 2019 has been reviewed. Patients who were diagnosed as sigmoid type 2 achalasia and underwent POEM were included in this study. Sigmoid type 2 achalasia was defined as an enormously dilated and tortuous esophagus in barium esophagram and double esophageal lumen in some CT slices. The primary outcome was the success rate, defined as an Eckardt Symptom Score(ESS) of less than 3 without additional treatments such as balloon dilation or redo POEM. The secondary outcomes were integrated relaxation pressure(IRP), mean lower esophageal sphincter(LES) pressure, and GERD after POEM. Patient’s characteristics: A total of 108 patients (age: 58.4±14.7 y/o, 51 females(47%), BMI: 21.7±4.6kg/m2) were included. Based on Chicago Classification, the type of achalasia seen were as follows: Type I/II/III= 28/8/1, and there were 71 unidentified cases due to the difficulty of inserting catheters. Diameter of esophagus was 48.1±17.5mm. Duration of symptoms was 17.4(7.7-29)years. ESS was 5(3-7). As pre-treatment, 49 patients had balloon dilation, Hellor-Dor in 8 patients, and Heller myotomy in 2 patients. Procedure-related parameters: Operation time was 95.9±32.1min. Myotomy length was 7(5-9)cm at the esophageal side, and 3(2-3)cm at the gastric side. Post-operative hospital stay was 4(4-5) days. The following complications were noted: mucosal perforation in 3 patients, submucosal hematoma or bleeding in 3 patients. Treatment outcomes: Success rate after 2 months was 89.1%(82/92). Pre- and 2-months post-POEM ESS were 5.0±2.5 and 1.1±1.0 (p<0.0001), respectively. Pre- and 2-months post-POEM IRP were 15.7±9.9 and 8.6±5.5 mmHg (p=0.0012), respectively. Pre- and 2-months post-POEM mean LES pressure were 19.9±13.9 and 14.6±7.7 mmHg (p=0.066), respectively. GERD 2-months post-POEM were as follows: Grade(N/A/B/C/D=37/29/13/7/1). Patients with GERD symptoms were 11.3%(10/88). PPI usage rate was 16.1%(13/81). Success rate after 1 year was 87.8%(43/49). Since good results of the short- and mid-term success rate and significant improvement of ESS and IRP value were achieved, POEM shows to be an effective procedure for sigmoid type 2 achalasia. Long-term results are expected in future studies.CT slice showing double esophageal lumenView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prolapsed rectal submucosal hematoma in pediatric case.

A rectal submucosal hematoma, imperfectly called a thrombosed external pile or external hemorrhoid, is a collection of blood within the skin around the anus, occurring due to a ruptured blood vessel within the submucosa usually caused by some minor trauma such as hard stool or due to severe constipation. Present case is a six year old girl child came into view with large mass coming out from anus with red dark-purple collection, pain and discomfort. She was unable to walk or sit. On examination no significant history of trauma except constipation, there was no history of per-rectal bleeding. Suddenly a swelling appeared after defecation. She was hospitalized for surgical excision. After hospitalization this swelling burst and reduced with discharge of clotted blood.

Intramural submucosal hematoma of esophagus due to anticoagulant treatment

Esophageal intramural submucosal hematoma is a rare and uncommon condition which occurs due to anticoagulant or antiplatelet treatment in the elderly population, or secondary to trauma.A 63-year-old female was presented to emergency with sudden onset hematemesis, back and chest pain left shoulder pain and sweating. She has a history of non-regulated hypertension and new diagnosed atrial fibrillation with using warfarin for a week. Except for high blood pressure, her physical examination was normal with long International Normalized Ratio (INR). For confirming cardiac pathologies (abdominal aortic aneurysm or dissection) echocardiography and intravenous contrast computerized tomography of chest and abdomen was performed Computed Tomography (CT) findings were consistent with an intramural esophageal hematoma. She hospitalized intensive care unit and was controlled regularly with blood tests and vital signs. After decreasing INR, gastroscopy was performed, and findings were consistent with an intramural esophageal hematoma. By hemodynamic stabilization oral intake was starting with fluid. Control esophagogastroscopy was performed to exclude any malignancy underlying hematoma and also showed regression of hematoma. She was recovered with conservative treatment. On the day of the sixteenth, she was discharged. Spontaneously submucosal esophageal hematoma due to anticoagulant or antiplatelet treatment in the elderly patient, is a rarely seen condition. By conservative treatment, most of the cases can be recovered.

A Case of Amyloid Light-Chain Amyloidosis Presenting With Submucosal Hematoma and Bleeding in the Upper Gastrointestinal Tract

A 65-year-old man taking no antithrombotic agents presented to our emergency department with hematemesis. Esophagogastroduodenoscopy (EGD) revealed large blood clots and active bleeding from the mucosa in the fundus and the cardia of the stomach (Figure A). The mucosa was so fragile that contact with the scope caused new bleeding. EGD showed a submucosal hematoma in the esophagus (Figure B), which was not observed when the examination started. Repeat EGD the following day showed hemostasis and multiple yellow deposits in the mucosa of the stomach and duodenum (Figure C).

1994 Spontaneous Intramural Intestinal Hematoma: An Increasing Phenomenon?

INTRODUCTION: The development of small bowel intramural hematomas is a rare process that is often seen in the young, precipitated by abdominal trauma. Non-traumatic, spontaneous, small bowel intramural hematomas are an even rarer entity, seen in the elderly and is associated with the overuse of anticoagulants. CASE DESCRIPTION/METHODS: 93 y/o male with past medical history of paroxysmal atrial fibrillation, deep vein thrombosis and pulmonary embolism, on anticoagulation, and diabetes mellitus type 2. He presented to the ED with abdominal pain, constipation, nausea and hematemesis with intermittent melena for 1 week. Anticoagulation was switched to edoxaban from warfarin given his unstable INR levels. Last dose of warfarin was 1 week prior to presentation. Patient denied prior abdominal trauma or NSAID use. On arrival, he had mild tachycardia and normotension. On exam, he had diffuse abdominal pain with mild rebound, no guarding. Labs were significant for coagulopathy INR &gt; 5.5, prothrombin time (PT) &gt; 95s, partial thromboplastin (PTT) time of 121s with stable thrombocytopenia Plt 126 (BILL/L) and hemoglobin Hgb 16.2 (g/dL). CT abdomen pelvis with contrast revealed circumferential wall thickening in the distal duodenum and proximal jejunum with no obstruction. Anticoagulation was held and he received IV fluids, fresh frozen plasma, prothrombin complex concentrate and vitamin K for coagulopathy and started on a protonix gtt. EGD revealed diffuse submucosal hematomas in the jejunum without ulcerations, confirming diagnosis of intestinal intramural hematomas. After medical management symptoms improved and he was discharged without anticoagulation. DISCUSSION: Spontaneous small bowel intramural hematomas are not often seen in patients admitted for acute abdominal pain. Although rare, intramural hematomas can have a devastating outcome. In this case, the patient was taking both warfarin and edoxaban, as evidenced by the lab findings. This likely doubled his risk for developing an intramural hematoma. Early imaging resulted in early diagnosis and prompt medical intervention. Prior cases have reported complications of obstruction, acute peritonitis, perforation, and hemorrhage shock. These lesions mostly affect the jejunum in 71.6% and duodenum in 29.8%. Thus, patients who present with non-specific abdominal pain and are on anticoagulant therapy, consider spontaneous intestinal intramural hematoma as a potential etiology. Early intervention may decrease complications and need of surgical intervention.