Sonographic diagnosis and monitoring of an intramural duodenal hematoma following upper endoscopic biopsy in a child

Ultrasound assessment of the bowel: inflammatory bowel disease and conditions beyond

Ultrasound (US) is a versatile imaging study for the evaluation of the bowel in children. US imaging of the bowel can be used as the initial examination or in follow-up for many common pediatric diseases. In this article, we highlight our bowel US technique and describe how US can depict the features of a select group of bowel pathologies relevant to pediatric practice.

Biopsy-Induced Duodenal Hematoma Is Not an Infrequent Complication Favored by Bone Marrow Transplantation

OBJECTIVES

Intraduodenal hematoma (IDH) is an uncommon complication of endoscopic duodenal biopsy that can cause severe obstruction of the digestive, biliary, or pancreatic tracts. We aimed to analyze the risk factors and outcomes of biopsy-induced IDH in our series.

METHODS

Between 2010 and 2014, a retrospective chart review was conducted for all children younger than 18 years of age treated for IDH. We collected their data in our tertiary pediatric center and compared them to those of controls matched for age, sex, and pathology.

RESULTS

Among 2705 upper nontherapeutic endoscopies and 1163 duodenal biopsies, 7 IDH occurred in 6 children suspected of developing graft-versus-host disease (GVHD) after bone marrow transplantation (BMT) and in 1 patient with Noonan syndrome. The IDH prevalence was significantly higher after BMT compared to children who did not undergo grafting (7% vs 0.1%; P = 7.9 × 10; odds ratio = 82). After a median delay of 48 hours, patients developed intestinal obstruction with abdominal pain and vomiting. The diagnosis was confirmed by using ultrasonography or computed tomography scans. Acute pancreatitis was determined in 3 out of 7 patients. Conservative treatment allowed complete resolution in all patients.

CONCLUSIONS

IDH is not an infrequent complication of endoscopic duodenal biopsy, especially in patients who undergo BMT. Endoscopists should be especially careful during the duodenal biopsy procedure in these patients. With no early perforation due to post-biopsy IDH reported, the prognosis is good and conservative management generally leads to resolution of the symptoms in 2 to 3 weeks.

An unusual case of hematemesis in a 12-month-old

A 12-month-old male with a history of failure to thrive and hypothyroidism presented to a pediatric emergency department twice in a 24-hour period with complaint of hematemesis. The patient had a recent upper endoscopy and biopsy as part of a work-up for failure to thrive, but had no other pertinent positives in clinical history. Ultrasound demonstrated findings concerning for an intramural duodenal hematoma. The patient was admitted to the gastroenterology service for intravenous hydration and nasogastric decompression. He did not require any invasive management or blood products. Duodenal hematoma is a known, but very uncommon complication of upper endoscopy.

Postendoscopic duodenal hematoma in children: ultrasound diagnosis and follow-up

Intramural duodenal hematomas have most frequently been reported in children in a traumatic setting. We present two cases of duodenal hematoma that occurred after upper gastrointestinal tract endoscopy with biopsy in children without significant prior medical history. The diagnosis was made by ultrasound, in correlation with the clinical presentation. Because the patients were hemodynamically stable, they were treated conservatively and the regression of the hematoma was followed up with ultrasound until its complete resolution. These cases demonstrate the risks of endoscopy, which are not to be neglected even in children without impaired coagulation, and the manner in which ultrasound can provide the correct diagnosis and follow-up.

Duodenal haematoma following endoscopy as a marker of coagulopathy

BACKGROUND

Intramural duodenal haematomas (IDHs) are a rare complication of endoscopic biopsy but can cause significant morbidity and mortality, including duodenal obstruction, hospitalization and needing intravenous feeding. They are extremely uncommon in those with normal haematology.

OBJECTIVE

To describe the occurrence of IDHs following endoscopic biopsy in our institution.

MATERIALS AND METHODS

We identified three patients who developed a post biopsy IDH during an 18-month period (2010-2012) in a retrospective search of our hospital pathology and imaging databases.

RESULTS

All three children had complex medical problems and presented with gastrointestinal symptoms including severe abdominal pain, reflux, poor feeding and abnormal gut transit time. All underwent normal upper GI endoscopy with duodenal biopsy. Following endoscopy, they presented with intermittent GI obstruction with severe abdominal pain, distension and bilious vomiting or symptoms of pancreatitis, had imaging features of IDH and were managed conservatively making a full recovery. Initial haematology including platelet counts were normal, but two children were subsequently found to have platelet dysfunction and the third to have an unclassified coagulopathy.

CONCLUSION

IDHs may be the presenting factor in children with unsuspected bleeding problems. We present these findings to raise awareness of the imaging features and clinical impact of these cases because better understanding of these risk factors may help to avoid these complications in children in the future.

Intramural duodenal haematoma after endoscopic biopsy: case report and review of the literature

The development of intramural duodenal haematoma (IDH) after small bowel biopsy is an unusual lesion and has only been reported in 18 children. Coagulopathy, thrombocytopenia and some special features of duodenal anatomy, e.g. relatively fixed position in the retroperitoneum and numerous submucosal blood vessels, have been suggested as a cause for IDH. The typical clinical presentation of IDH is severe abdominal pain and vomiting due to duodenal obstruction. In addition, it is often associated with pancreatitis and cholestasis. Diagnosis is confirmed using imaging techniques such as ultrasound, magnetic resonance imaging or computed tomography and upper intestinal series. Once diagnosis is confirmed and intestinal perforation excluded, conservative treatment with nasogastric tube and parenteral nutrition is sufficient. We present a case of massive IDH following endoscopic grasp forceps biopsy in a 5-year-old girl without bleeding disorder or other risk for IDH, which caused duodenal obstruction and mild pancreatitis and resolved within 2 weeks of conservative management. Since duodenal biopsies have become the common way to evaluate children or adults for suspected enteropathy, the occurrence of this complication is likely to increase. In conclusion, the review of the literature points out the risk for IDH especially in children with a history of bone marrow transplantation or leukaemia.

Acute pancreatitis secondary to intramural duodenal hematoma: Case report and literature review

Nontraumatic intramural duodenal hematoma (IDH) is rare disease and it is generally related to coagulation abnormalities. Reports of nontraumatic IDH associated with pancreatic disease are relatively rare, and various conditions including acute or chronic pancreatitis are thought to be associated with nontraumatic IDH. However, the association between IDH and acute pancreatitis remains unknown. We report the case of a 45-year-old man who presented with vomiting and right hypochondrial pain. He had no medical history, but was a heavy drinker. The diagnosis of IDH was established by computed tomography, ultrasonography and endoscopy, and it was complicated by acute pancreatitis. The lesions resolved with conservative management. We discuss this case in the context of previously reported cases of IDH concomitant with acute pancreatitis. In our patient, acute pancreatitis occurred concurrently with hematoma, probably due to obstruction of the duodenal papilla, or compression of the pancreas caused by the hematoma. The present analysis of the published cases of IDH with acute pancreatitis provides some information on the pathogenesis of IDH and its relationship with acute pancreatitis.