Submucosal Hematoma Research Articles

Oesophageal submucosal hematoma after flow diverter embolization with favourable outcome treated by discontinuing postoperative antiplatelet therapy for only three\xa0days: a case report

BackgroundOesophageal submucosal hematoma is a rare perioperative complication. When this complication develops after endovascular surgery, which requires postoperative antiplatelet therapy, whether to stop antiplatelet therapy or not is controversial. If antiplatelet therapy is discontinued, the appropriate time to resume antiplatelet therapy is unclear.Case presentationA 75-year-old woman (height 134 cm, weight 37 kg) underwent flow diverter embolization for unruptured cerebral aneurysm under general anaesthesia. The patient received dual antiplatelet therapy before surgery and anticoagulation therapy intraoperatively. After surgery, the patient developed hematemesis and was diagnosed with oesophageal submucosal hematoma. Conservative treatment was initiated after discontinuing antiplatelet therapy, which was resumed 3 days after surgery. The patient showed good recovery even after the resumption of antiplatelet therapy.ConclusionsIn our case, we successfully treated oesophageal submucosal hematoma developing after endovascular surgery with early resumption of postoperative antiplatelet therapy.

Outcomes of EUS-FNA in patients receiving antithrombotic therapy.

Background and study aims To investigate bleeding risk and thromboembolic risk in patients receiving antithrombotic therapy who underwent endoscopic ultrasound-guided fine-needls aspiration (EUS-FNA). Patients and methods A single-center retrospective study of 908 consecutive patients undergoing EUS-FNA for pancreatic and non-pancreatic lesions patients between March 2013 and March 2017 was performed. Antithrombotic management was classified into three groups: continuous, discontinuation, and heparin replacement. Results A total of 114 patients (12.6 %) were on antithrombotic drugs and 794 (84.6 %) were not. There were six cases of significant bleeding (0.7 %) four in the antithrombotic group (0.4 %) and two (0.2 %) in the non-antithrombotic group, (odds ratio, 9.59; 95 % confidence interval, 2.12 – 43.1; P = 0.006). Of the four cases in the antithrombotic group, two were on continuous treatment, one was on discontinuation treatment and one was on heparin replacement. All cases of non-significant bleeding occurred in the non-antithrombotic group (3 peri-tumoral hematomas, 1 submucosal hematoma, and 1 intraluminal bleed). The sole thromboembolic event (0.9 %) was a cerebral infarction in the antithrombotic group in a patient on thienopyridine who switched to aspirin before the procedure. Conclusions There was a slight increase in risk of bleeding in patients receiving antithrombotic therapy especially postoperative bleeding; however, there were no cases of severe bleeding was seen and only one case of cerebral infarction which occurred in a high-risk thromboembolic patients. We concluded that EUS-FNA in a safe procedure for patients on antithrombotics, even when antithrombotic therapy is not discontinued during EUS-FNA.

A Case of Acquired Hemophilia A Diagnosed with Submucosal Hematoma of Oral Cavity

A Case of Acquired Hemophilia A Diagnosed with Submucosal Hematoma of Oral Cavity

A Rare Case of Bleeding Duodenal Arteriovenous Malformations in Association with Amyloid Enteropathy

Amyloidosis is a rare disease caused by accumulation of abnormal amyloid fibrils within the extracellular matrix leading to structural and functional disruption of the involved tissue. Gastrointestinal (GI) involvement is seen in primary, secondary and dialysis related amyloidosis. AVM's (arteriovenous malformations) in association with amyloidosis are a rare cause of GI bleed. We report an unusual case of duodenal AVM's associated with gastrointestinal amyloidosis (AL), presenting as an acute upper GI bleed. An 82-year old Caucasian male with history of coronary artery disease and atrial fibrillation on anticoagulation, presented with a complaint of melena. Physical examination was significant for pallor. Laboratory investigation revealed iron deficiency anemia with a hemoglobin of 7.9 g/dL. Subsequent EGD showed thickened small bowel polypoidal mucosal folds with multiple AVM's in the second and third portions of the duodenum, few of which were bleeding actively. APC (Argon Plasma Coagulation) therapy of the bleeding AVM's was performed with resultant satisfactory hemostasis. Mucosal biopsies of the thickened duodenal folds were also performed. Histology revealed amyloidosis involving the muscularis mucosa and vessels, which displayed an apple green birefringence under polarized light microscopy using Congo Red stain (Figure 1).2010 Figure 1. (a, arrow) Thickened polypoidal mucosal folds (b, arrow) Multiple AVM's visualized in the duodenum (c, arrow) Actively bleeding AVM (d) Duodenal wall H&E stain showed homogenous eosinophilic deposits of muscularis mucosa and vessels, suggestive of amyloid enteropathy; (e, arrow). Positive Congo red staining of amyloid deposits in the vessel (f) Apple green birefringence (arrow) of Congo red stain under fluorescence polarized microscopy confirmed amyloid rich deposition.Further laboratory investigation revealed a negative urine immunofixation test for monoclonal free and ? light chains. Mass spectroscopy revealed AL type amyloidosis, however the workup for plasma cell dyscrasias (multiple myeloma/Waldenstorm macroglobulinemia) was negative. GI tract involvement occurs more often with AA amyloidosis rather than with the AL type. Patients with amyloid enteropathy can present with GI bleeding, the etiology of which is usually secondary to ischemia, mucosal ulcers, and submucosal hematomas. Rarely AVM's have been found to be associated with amyloidosis. Published data has shown such association as with gastric and pulmonary AVM's. This case demonstrates a rare presentation of GI bleed in the setting of amyloid enteropathy secondary to duodenal AVM's. This is the first reported case of bleeding duodenal AVM's with amyloidosis. Hence it is our recommendation, that the presence of AVM's with thickened or polypoidal small bowel folds should prompt the endoscopist to rule out amyloidosis.

Clinical and endoscopic manifestations of gastrointestinal amyloidosis: a case series

Gastrointestinal (GI) amyloidosis is rare and has varying clinical and endoscopic presentations. In this case series, we present three patients with primary systemic amyloid-light chain (AL) amyloidosis with GI involvement and complications of GI bleeding. We also provide a brief review of the literature, including clinical presentation, endoscopic findings, pathology, and management of GI amyloidosis. The endoscopic findings of GI amyloidosis can vary, including friable mucosa with erosions, ulcers, and submucosal hematomas or mucosal thickening with polypoid protrusions. The endoscopic findings may correlate with the pathologic deposition of amyloid fibrils. Treatment of GI amyloidosis is generally focused on management of the underlying condition and supportive care. Gastroenterologists should be familiar with the endoscopic findings as they may be the first suggestion of disease and allow for definitive diagnosis.

Gastrointestinal: Huge submucosal hematoma of the stomach arising in a patient with vascular type Ehlers-Danlos syndrome.

Gastrointestinal: Huge submucosal hematoma of the stomach arising in a patient with vascular type Ehlers-Danlos syndrome.

Submucosal hematoma: a new distinctive sign during emergency upper digestive endoscopy for ammonia ingestion

BackgroundSubmucosal hematoma has never been associated with caustic injuries. Long-term follow-up of patients who ingested ammonia is not well known and ammonia ingestion is rare.MethodsIn a Single-center observational study, prospective data were collected from 2009 to 2013, in patients over the age of 14 years old referred for ammonia ingestion. The emergency and follow-up endoscopic data and the outcome were reported.ResultsAmmonia ingestion occurred in 43 patients. Submucosal hematoma of the gastric wall was a distinctive endoscopic sign observed in 15 (34.8%) cases. Oropharyngeal lesions were present in 30 (69.8%) patients, which was associated with ingestion with suicidal intent in 18 cases. Mild and severe endoscopic lesions (grade IIB to IIIB) were found in 16 (37.2%) cases with 10 (23.3%) cases presenting submucosal hematoma at initial endoscopy. A complete spontaneous gastric healing was frequently observed in 36 (83.7%) cases. In 11 cases with submucosal hematoma, a favourable outcome was observed with a medical treatment, however 6 of these patients had severe endoscopic lesions initially.ConclusionsSubmucosal hematoma of the gastric wall is an endoscopic sign occurring frequently in ammonia ingestion. Submucosal hematoma should be distinguished from necrosis in order to avoid false misclassification in favour of more severe lesions, which would lead to an abusive surgery.

A case of giant gastric submucosal hematoma treated with transcatheter embolization

A case of giant gastric submucosal hematoma treated with transcatheter embolization

A case of gastric and colonic submucosal hematomas with amyloidosis

A case of gastric and colonic submucosal hematomas with amyloidosis

Tu1142 ADVERSE EVENTS OF PER-ORAL ENDOSCOPIC MYOTOMY (POEM) ∼SINGLE INSTITUTE RETROSPECTIVE ANALYSIS OF 1550 CASES ∼

POEM has been widely accepted and currently been performed at various institutions worldwide. Although POEM is considered a safe treatment with favorable outcomes, adverse events have been reported. The aim of this study was to investigate the adverse events encountered in our institution. We conducted a retrospective cohort study of patients who underwent POEM at a single tertiary referral center in Tokyo, Japan between September 2008 and October 2017. We have reviewed all adverse events we encountered during this time period. We defined adverse events as follows: Gastric mucosal injury: perforation or ulceration of gastric mucosa. Massive bleeding: intraprocedural bleeding requiring blood transfusions. Gastroesophageal reflux disease (GERD): acid reflux symptoms over 2 months requiring PPI. Severe reflux esophagitis: acid reflux symptoms refractory to conservative treatment such as oral administration of PPI. 1,500 cases of POEM were performed between September 2008 and October 2017. We have experienced 40 (2.6%) cases of mucosal injury, 7 (0.4%) submucosal hematoma, 3 (0.2%) mediastinitis, 2 (0.1%) intraprocedural bleeding requiring transfusion, 1 (0.1%) pneumothorax and 2 (0.1%) severe reflux esophagitis. Although one patient required drainage for pneumothorax, there were no serious adverse events requiring surgical intervention. Follow-up gastroscopy was routinely performed in 2 months. There were findings of GERD Los Angeles classification grade A/B in about half of the patients, however there were only 6% of the patients with GERD Los Angeles grade C / D. Post-POEM reflux symptoms were present in 16% and 13% required to long-term oral PPI treatment. The risk of GERD symptoms tends to slightly increase after posterior wall approach, however there is a possibility that myotomy of sling muscle fibers may have been the cause of GERD symptoms. Two patients were refractory to PPI and one of the cases underwent anti-reflux mucosectomy (ARMS) and another case underwent surgical fundoplication. POEM is a highly safe procedure, and almost all adverse events could be managed conservatively.

Esophageal submucosal hematoma developed after endovascular surgery for unruptured cerebral aneurysm under general anesthesia: a case report

BackgroundEsophageal submucosal hematoma is a rare complication after endovascular surgery. We report a case of an esophageal submucosal hematoma which may have been caused by rigorous cough during extubation.Case presentationA 75-year-old woman underwent endovascular treatment for unruptured cerebral aneurysm under general anesthesia. The patient received aspirin and clopidogrel before surgery and heparin during surgery. Activated clotting time was 316 s at the end of surgery. Protamine was not administered and continuous infusion of argatroban was started after surgery. She had a rigorous cough during removal of the tracheal tube and reported retrosternal discomfort postoperatively. She developed hemorrhagic shock after massive hematemesis. A diagnosis of esophageal submucosal hematoma was made by endoscopic examination and computed tomography. Hemostasis was achieved by compression with a Sengstaken-Blakemore tube and endoscopic cauterization. Blood pressure was recovered by blood transfusion. Endoscopic examination performed 7 days after surgery showed that esophageal submucosal hematoma had almost disappeared and slough had adhered to the mucosal laceration. The patient showed good recovery and was discharged 21 days after surgery.ConclusionsCareful extubation and postoperative observation are required in patients receiving antiplatelet and anticoagulant therapy.

Colonic Amyloidoma: A Rarely Encountered Finding

Amyloidosis is a systemic disease characterized by the extracellular deposition of abnormal protein fibrils throughout the body that disrupts normal tissue architecture and function. It can present in many different forms, but the most common form that affects the gastrointestinal tract (GIT) is amyloid light-chain (AL) amyloidosis. Although amyloid deposition in the GIT is not uncommon, less than 50% will develop GI symptoms including GI dysmotility, malabsorptive diarrhea, spontaneous hemorrhage, and pseudo-obstruction. Early diagnosis of AL amyloidosis is essential because most cases are diagnosed late and associated with a poor prognosis. If left untreated it can carry median 1-year mortality rate of approximately 50%. Identifying the classic findings of AL amyloidosis during endoscopy should prompt further evaluation for disease. Our patient is a 54-year-old man with a past medical history significant for AL amyloidosis diagnosed on renal biopsy, who presented with worsening hematochezia. He also reported recurrent abdominal pain, a 60-pound weight loss, chronic diarrhea, and recurrent syncope for the last 4 months. Hemoglobin was 8.4 g/dL on admission. Colonoscopy revealed multiple large and small hemorrhagic polypoid lesions. The largest lesion filled approximately 75% of the colon. Multiple blood clots were also identified, but no active bleeding was seen during endoscopy. Endoscopic biopsies were not pursued given significant bleeding risk and prior diagnosis of AL amyloidosis. AL amyloid deposition within the vascular walls of the GIT increases vessel fragility and can result in hemorrhage beneath the lamina propria, forming submucosal hematomas. During endoscopy, submucosal hematomas appear purple and have a polypoid appearance with a shelf-like base. Other common findings during endoscopy include: mucosal ulcerations, intestinal erosions, yellowish plaque-like infiltrative lesions, and thickened mucosal folds. Rarely, as evident in our case, patients may have tumor-forming deposits of amyloid called amyloidomas, which can be wrongly diagnosed as a primary or metastatic GI malignancy. Given the poor prognosis associated with AL amyloidosis, recognizing common endoscopic findings should prompt the endoscopist to maintain a high index of suspicion and diagnose amyloidosis to improve overall prognosis.Figure: Endoscopy Findings.

Intramural Duodenal Hematoma Complicating Endoscopic Biopsy Presenting With Gastric Outlet Obstruction and Acute Pancreatitis

Intramural duodenal hematoma (IDH) complicating endoscopic biopsy is rare in adults. It is more commonly seen in children, and in patients with underlying risk factors, such as trauma, coagulopathy, platelet dysfunction, anticoagulant therapy and endoscopic intervention. We describe a patient without underlying risk factors, who developed IDH following endoscopy with biopsies. The patient presented with a gastric outlet obstruction (GOO) and acute pancreatitis, and resolved with conservative therapy. A 28 year-old healthy male presented with epigastric pain radiating to his back, nausea, vomiting (non-bloody, non-bilious), and intractable hiccups few hours after an upper endoscopy. The endoscopy was performed for evaluation of reflux, dysphagia, and weight loss. Endoscopy revealed reflux esophagitis without strictures. Duodenal, gastric and esophageal biopsies were taken using a standard sized biopsy forceps. He denied any recent trauma or alcohol use and had no history of bleeding tendencies, or medication use. Physical examination showed tachycardia, epigastric tenderness, and bowel sounds were present. Stool was negative for occult blood. Laboratory evaluation showed a white blood count of 13,700/mm3, lipase of 10,830 IU/L, and bilirubin of 3.5 mg/dl (predominately direct). Other liver biochemistries were normal. Extensive testing did not reveal any coagulopathy or platelet dysfunction. CT scan of abdomen with oral contrast was remarkable for thickening of the duodenal wall to 5 cm with lack of emptying of contrast beyond the duodenal bulb. Pathology showed normal mucosal biopsies. Nasogastric suction yielded the return of 1.3 liters of non-bilious, non-bloody fluid. Endoscopy performed on day 5 revealed a GOO caused by submucosal duodenal hematomas with compression of the ampulla of vater. No other hematomas were visualized. The patient responded to conservative therapy and was discharged on a general diet on day 7. We describe the rare complication of IDH following upper endoscopy with standard biopsies in an adult without any risk factors. The IDH was severe enough to cause GOO and acute pancreatitis. The pancreatitis was caused by visually observed ampullary compression by the IDH. Our patient responded well to conservative therapy. IDH should be considered in a patient presenting with gastric outlet obstruction and/or acute pancreatitis following an otherwise uneventful upper endoscopy with biopsies.Figure: Gastric outlet obstruction showing oral contrast in the stomach with a cutoff at the duodenal bulb.Figure: IDH compressing ampulla of vater.Figure: IDH occluding duodenal lumen.

Comparison of clinical outcomes of multi-point umbrella suturing and single purse suturing with two-point traction after procedure for prolapse and hemorrhoids (PPH) surgery

ObjectivesTo compare the clinical outcomes of multipoint umbrella suture and single-purse suture with two-point traction after procedure for prolapse and hemorrhoids surgery (PPH) for the treatment of mixed hemorrhoids. MethodsNinety patients were randomly divided into a PPH plus single-purse suture group (Group A) and a PPH plus multipoint umbrella suture (Group B). All operations were performed by an experienced surgeon. Operation time, width of the specimen, hemorrhoids retraction extent, postoperative pain, postoperative bleeding, and length of hospitalization were recorded and compared. Statistical analysis was conducted by t-test and χ2 test. ResultsThere were no significant differences in sex, age, course of disease, and degree of prolapse of hemorrhoids between the two groups. The operative time in Group A was significantly shorter than that in Group B (P < 0.05). However, the incidence rates of submucosal hematoma and incomplete hemorrhoid core retraction were significantly lower in Group B (P < 0.05), whereas the width of the specimens in Group B was greater than that in Group A (P < 0.05). There were fewer redundant skin tags in Group B at three months follow-up. No significant difference in postoperative pain, postoperative bleeding, and time of hospital stay (P > 0.05 for all comparisons) was observed. ConclusionThe multipoint umbrella suture showed better clinical outcomes because of its targeted suture according to the extent of hemorrhoid prolapse.

Acute submucosal hematoma: an adverse event of routine colonoscopy

Acute submucosal hematoma: an adverse event of routine colonoscopy

Systemic AL Amyloidosis with Colonic Submucosal Hematoma.

Systemic AL Amyloidosis with Colonic Submucosal Hematoma.

Submucosal Hematoma of the Sigmoid Colon Due to Anticoagulation Therapy

Submucosal Hematoma of the Sigmoid Colon Due to Anticoagulation Therapy

吐血時の粘膜下血腫観察を契機に食道アミロイドーシスと診断した1例

吐血時の粘膜下血腫観察を契機に食道アミロイドーシスと診断した1例

Frontal Sinus Barotrauma.

A 58-year-old woman visited our hospital’s emergency department because of a severe and increasing pain over the right occipital region, irradiating over the right frontal area. The pain started during the descent of a jet airplane on a holiday trip. There were no visual or hearing deficits, head trauma, or epistaxis, and she experienced no difficulty clearing her ears during the flight. Only a minor respiratory tract infection was noted two weeks before this episode, and she had no history of sinus problems. The pain was nothing like previous migraine headaches she had experienced. A noncontrast CT scan was performed which showed no apparent abnormal findings, except for a soft tissue density in the right frontal sinus, initially interpreted as an inflammatory mucosal swelling. Because of the atypical and persistent headache, MRI imaging was performed to exclude underlying pathology. No intracranial mass, hemosiderin deposits, or arteriovenous malformation were observed. A polypoid mass was noted in the right frontal sinus, hyperintense on T1and T2-weighted images, without enhancement after contrast administration (Figures A and B). Considering the clinical history and MRI appearance, the diagnosis of submucosal hematoma secondary to barotrauma was made. Conservative treatment with oral decongestants and analgesics resulted in satisfactory symptom relief.

An unusual endoscopic image of a submucosal esophageal hematoma

An unusual endoscopic image of a submucosal esophageal hematoma