Korean J Gastroenterol.  2019 Jan;73(1):39-44. 10.4166/kjg.2019.73.1.39.

Huge Intramural Duodenal Hematoma Complicated with Obstructive Jaundice following Endoscopic Hemostasis

• Kim HS
• Kim HK
• Kim WH
• Hong SP
• Cho JY

• KMID: 2432435
• DOI: http://doi.org/10.4166/kjg.2019.73.1.39

Abstract

Intramural hematoma of the duodenum is a relatively unusual complication associated with the endoscopic treatment of bleeding peptic ulcers. Intramural hematomas are typically resolved spontaneously with conservative treatment alone. We report a case of an intramural duodenal hematoma following endoscopic hemostasis with epinephrine injection therapy, which was associated with transient obstructive jaundice in a patient undergoing hemodialysis. The patient developed biliary sepsis due to obstruction of the common bile duct secondary to the huge hematoma. He was treated with fluoroscopy-guided drainage catheter insertion, which spontaneously resolved the biliary sepsis through conservative treatment in 6 weeks. Fluoroscopy-guided drainage may impact the treatment of intramural hematomas that involve life-threatening complications.

Keyword

Duodenal ulcer; Hematoma; Cholestasis; Drainage

MeSH Terms

Catheters
Cholestasis
Common Bile Duct
Drainage
Duodenal Ulcer
Duodenum
Epinephrine
Hematoma*
Hemorrhage
Hemostasis, Endoscopic*
Humans
Jaundice, Obstructive*
Peptic Ulcer
Renal Dialysis
Sepsis
Epinephrine

Figure

• 

  Fig. 1 Endoscopic findings. (A) The esophago-gastro-duodenoscopy on admission revealed a deep ulcer and an exposed vessel on the base was noted at the duodenal bulb. (B) An epinephrine injection (2 mL, 1 mL) was administered to control the blood oozing from the vessel. Complete hemostasis was acquired with four hemoclippings and 2 mL of fibrin glue injection.

• 

  Fig. 2 On the 2nd hospital day, the contrast-enhanced abdominal computed tomography scan showed a huge intramural hematoma in the 2nd to 4th portions of the duodenum with compression of the common bile duct (black arrows, intramural hematoma; white arrows, common bile duct). (A) Axial image. (B) Coronal image.

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  Fig. 3 Fluoroscopic finding. An 8-Fr pigtail catheter was inserted through the right transhepatic access to the duodenal submucosal hematoma.

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  Fig. 4 Six days after catheter insertion, the follow-up abdominal computed tomography showed partial regression of the intramural hematoma and mild improvement of the common bile duct obstruction. A marked increase in loculated fluid collection was shown in the right abdomen with fistula formation leading to the retroperitoneum from the duodenal submucosal hematoma (black arrows, hematoma fluid loculation; arrowheads, fistula; white arrows, common bile duct). (A) Axial image. (B) Coronal image.

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  Fig. 5 After 4 weeks of catheter drainage, the follow-up abdominal computed tomography showed near resorption of the hematoma in the submucosal area of the duodenum and decreased loculated fluid collection in the right abdomen (black arrow, resolved intramural hematoma; white arrows, decreased loculated fluid). (A) Axial image. (B) Coronal image.

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  Fig. 6 Esophago-gastro-duodenoscopy at 8 weeks revealed the healed duodenal ulcer without any evidence of hematoma.

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