Bowel obstruction caused by an intramural duodenal hematoma: a case report of endoscopic incision and drainage

Abstract

Complications associated with an intramural hematoma of the bowel, is a relatively unusual condition. Most intramural hematomas resolve spontaneously with conservative treatment and the patient prognosis is good. However, if the symptoms are not resolved or the condition persists, surgical intervention may be necessary. Here we describe internal incision and drainage by endoscopy for the treatment of an intramural hematoma of the duodenum. A 63-yr-old woman was admitted to the hospital with hematemesis. The esophagogastroduodenoscopy (EGD) showed active ulcer bleeding at the distal portion of duodenal bulb. A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally. The patient developed diffuse abdominal pain and projectile vomiting three days after the endoscopic treatment. An abdominal computed tomography revealed a very large hematoma at the lateral duodenal wall, approximately 10 x 5 cm in diameter. Follow-up EGD was performed showing complete luminal obstruction at the second portion of the duodenum caused by an intramural hematoma. The patient's condition was not improved with conservative treatment. Therefore, 21 days after admission, endoscopic treatment of the hematoma was attempted. Puncture and incision were performed with an electrical needle knife. Two days after the procedure, the patient was tolerating a soft diet without complaints of abdominal pain or vomiting. The hematoma resolved completely on the follow-up studies.

Keywords: Drainage; Duodenum; Hematoma, Intramural.

Fig. 1

Esophagogastroduodenoscopy on admission revealed multiple active ulcerations with large amounts of fresh blood clots and necrotic tissue materials at the distal portion of duodenal bulb (A). A total of 10 mL of 0.2% epinephrine and 2 mL of fibrin glue were injected locally (B).

Fig. 2

Contrast-enhanced abdominal CT scan findings on the 3rd hospital day. A very large hematoma at the lateral duodenal wall, approximately 10×5 cm in diameter was identified. In the hematoma, active bleeding from vessel was revealed (arrow).

Fig. 3

EGD on the 4th hospital day revealed severe stenosis of the second portion of the duodenum due to an intramural hematoma. The surface of the hematoma appeared to be covered with normal mucosa but was friable and red in color.

Fig. 4

EGD findings on the 21st hospital day. The hematoma was punctured and incised with an electrical needle knife (A). Soon after, a large amount of liquefied dark red colored material gushed out from the hematoma, and the obstructed bowel lumen was repaired (B).

Fig. 5

Follow-up EGD Findings. EGD Seven days after EGD showed that the duodenal stenosis was partially improved and the incision site was ulcerated (A). One month after EGD showed that the duodenal stenosis was almost completely resolved, and the entire hematoma collapsed. The ulcer was completely healed (B).