Intramural hematoma: a rare complication of endoscopic injection therapy for bleeding peptic ulcers

Spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma: a rare case

BACKGROUND

Gastric intramural hematoma is a rare disease. Here we report a case of spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma.

CASE PRESENTATION

A 75-years-old man was admitted to our department with complaints of abdominal pain. He underwent a whole abdominal computed tomography (CT) scan in the emergency department, which showed extensive thickening of the gastric wall in the gastric body and sinus region with enlarged surrounding lymph nodes, localized thickening of the intestinal wall in the transverse colon, localized indistinct demarcation between the stomach and transverse colon, and a small amount of fluid accumulation in the abdominal cavity. Immediately afterwards, he was admitted to our department, and then we arranged a computed tomography with intravenously administered contrast agent showed a spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. Therefore, we treated him with anticoagulation and conservative observation. During his stay in the hospital, he was given low-molecular heparin by subcutaneous injection for anticoagulation therapy, and after discharge, he was given oral anticoagulation therapy with rivaroxaban. At the follow-up of more than 4 months, most of the intramural hematoma was absorbed and became significantly smaller, and the intermural hematoma of the superior mesenteric artery was basically absorbed, which also confirmed that the intramural mass was an intramural hematoma.

CONCLUSION

A gastric intramural hematoma should be considered, when an intra-abdominal mass was found to be attached to the gastric wall. Proper recognition of gastric intramural hematoma can reduce the misdiagnosis rate of confusion with gastric cancer.

An unusual complication after endoscopic clipping of a gastric ulcer

A 72-year-old patient presented with malaena secondary to two antral ulcers which were discovered in oesophagogastroduodenoscopy (OGD) after admission. One of the ulcers with a visible vessel was injected with adrenaline and clipped with an OVESCO clip. The patient continued to have coffee ground vomitus on the following day with a drop in haemoglobin level. Repeat OGD showed a large intra-mural haematoma with the clip still in situ and no bleeding from the surface of the ulcer. Patient underwent a coil embolization of the distal gastroduodenal artery (GDA), right gastroepiploic artery and a medial branch of the GDA. Repeat OGD showed that the submucosal haematoma had evacuated, leaving a large, clean-based mucosal defect.

A Rare Case of Gastric Intramural Hematoma in Recurrent Leukemia

Gastric intramural hematoma (GIH) is a rare disorder that usually arises secondary to another condition or intervention, and less often occurs without an identifiable cause. Computed tomography (CT), as performed in this case, is the diagnostic modality of choice. The treatment comprises conservative measures, a minimally invasive approach, or surgical intervention. We present a case of recurrent acute lymphoblastic leukemia (ALL) as a new etiology for GIH that was managed conservatively to highlight the importance of including GIH in the differential for a patient with ALL, a drop in hemoglobin level, and vague gastrointestinal symptoms.

Large Duodenal Hematoma Causing an Ileus after an Endoscopic Duodenal Biopsy in a 6-Year-Old Child: A Case Report

Intramural duodenal hematoma (IDH) in children is a rare complication after esophagogastroduodenoscopy. It is commonly described in patients with additional disorders or risk factors, such as coagulopathy. We present a case of a previously healthy 6-year-old boy with a large obstructing intramural duodenal hematoma and concomitant pancreatitis after an elective esophagogastroduodenoscopy. The patient presented with typical symptoms of an IDH, such as abdominal pain and distension, nausea and vomiting. IDH was diagnosed using ultrasound and magnetic resonance imaging examination. Conservative management with gastric decompression using a nasogastric feeding tube, bowel rest, total parenteral nutrition and analgesia was performed. After three weeks, the patient was discharged from the hospital without any complaints. Interventional management of IDH in pediatric patients with a lack of response to conservative therapy or complicating IDH should be discussed in an interdisciplinary team.

Gastric intramural hematoma subsequent to thoracic aortic dissection: Case report and literature review

Introduction

Intramural hematomas of the gastrointestinal tract are uncommom, usually located in the esophagus or duodenum, with idiophatic or secondary causes. We present a very rare case of gastric intramural hematoma caused by an unpublished etiology, with literature review.

Case presentation

An elderly woman suffered acute thoracic aorta dissection followed by gastric intramural hematoma, diagnosed through endoscopy and computed tomography angiography. The treatment included endovascular aortic repair and conservative management.

Discussion

The postulated mechanism for the bleeding in gastric intramural hematoma is shredding of terminal arteries at the point of penetration into the muscular layer with subsequent dissection of the muscularis propria from the submucosa. The most frequently cited risk factor is hemorrhagic diathesis/anticoagulant use and the main etiologies are trauma and post-interventional endoscopy. In the diagnosis work-up, computed tomography is the method of choice, usually associated with endoscopy. There is no standard of care for such rare condition. Thus, treatment may be cause-dependent, ranging from conservative to minimally invasive and/or surgery.

Conclusions

Gastric intramural hematoma is a rare disorder with many causes and we described a new etiology for it. The computed tomography is the diagnostic modality of choice, with the aid of other examinations. The treatment comprises conservative measures, minimally invasive approach or most commonly surgery.

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Gastric intramural hematoma is very rare.

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It is important to be familiarized with it, since it has so many different causes.

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This article presents a new cause for gastric intramural hematoma.

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Treatment may be conservative, minimally invasive or surgical.

Intramural gastric hematoma imitating a gastrointestinal stromal tumor - case report and literature review

The article presents a case report of a patient with an intramural gastric hematoma. Diagnostic examinations were suggestive of a suspected gastrointestinal stromal tumor Normal image was observed in gastroscopic examination while abdominal CT scan revealed a nodular lesion along the greater curvature of the stomach extending from the posterior wall and adjoining the pancreas and the spleen. The patient was qualified for surgical treatment. Laparotomy was performed followed by total gastric resection and Roux-en-Y reconstruction of the gastrointestinal tract. Post-operative histopathological examination revealed the presence of an extensive hematoma penetrating the perigastric fat tissue along with numerous hemosiderinophages and segmental indicators of formation of inflammatory granulation tissue suggestive of a chronic nature of the lesion. Immunohistochemical GIST assays (CD117, DOG-1, CD34, CD31, SMA, S-100, CKAE1/AE3, Ki-67) were negative. No complications were observed in the post-operative course. Patient is subject to continued follow-up and observation. Follow-up gastroscopy and abdominal CT scan performed 6 months after the surgery revealed an unremarkable image.

A belly of blood: A case report describing surgical intervention in a gastric intramural haematoma precipitated by therapeutic endoscopy in an anticoagulated patient

Gastric intramural hematoma, "intramural dissection" or "false aneurysm", is a rare and dangerous condition which may be more broadly classified as a spectrum of acute gastric mucosal injury. It is postulated that disruption of the mucosa and blood vessels within the submucosal layer results in dissection of the muscularis propria from the mucosa, with eventual clot formation. While a majority of cases resolve with conservative management, we describe a successfully managed case requiring surgical intervention. Progression of the haematoma was documented both endoscopically and surgically in an elderly anticoagulated patient who suffered a complication of therapeutic endoscopic intervention. A review of the literature is presented.

Esophagogastroduodenal pneumatosis with subsequent pneumoporta and intramural duodenal hematoma after endoscopic hemostasis: a case report

BACKGROUND

Esophagogastroduodenal pneumatosis is the presence of air in esophagus, stomach, and duodenum simultaneously, which have never been described in the literature. Intramural duodenal hematoma (IDH) rarely occurs after endoscopic intervention. The diagnosis and treatment in both conditions are great challenge in daily practice.

CASE PRESENTATION

A 70-year-old male patient, who had been taking warfarin for artificial valve replacement, developed IDH and esophagogastroduodenal pneumatosis after endoscopic hemostasis for duodenal ulcer bleeding. Initially, he had abdominal pain, gastrointestinal bleeding and hypotension. Later, he was found to have acute pancreatitis, biliary obstruction, gastric outlet obstruction and rapid decline of hemoglobin also ensued. The intramural duodenal hematoma and critical condition resolved spontaneously after conservative medical treatment.

CONCLUSION

Based on this case report, we suggest that intramural duodenal hematoma should be considered if a patient has the tetrad of pancreatitis, biliary obstruction, gastric outlet obstruction and rapid decline of hemoglobin after an endoscopic intervention. Those patients could be treated conservatively. But, surgery should be considered if the diseases progress or complications persist.

Safety analysis of a hemostatic powder in a porcine model of acute severe gastric bleeding

BACKGROUND

Non-variceal upper gastrointestinal (UGI) bleeding is a common condition that requires prompt lifesaving therapy and traditional endoscopic treatments require high technical proficiency to perform.

AIMS

This study was conducted to identify any local or systemic histopathologic effects of a hemostatic powder in a porcine model of active, severe, non-variceal UGI hemorrhage.

METHODS

This prospective, non-blinded animal study was performed in accordance with Good Laboratory Practice and Animal Care and Use Guidelines. Six animals underwent gastrotomy and creation of a looped vascular bundle, which was placed into the stomach lumen. The transplanted vascular bundle was punctured with an endoscopic needle-knife to create Forrest grade Ia or Ib bleeding. The hemostatic powder was then applied until hemostasis was achieved.

RESULTS

Initial hemostasis was achieved in all animals. Results of pre- and post-treatment coagulation studies were similar. All animals survived at least 9 days post-procedure. The hemostatic powder was not found in any local, regional, or systemic tissues. Gross and histologic analysis of systemic organs showed no infarct, particulate, or embolic effects. No gross or microscopic necropsy findings were treatment-related.

CONCLUSIONS

The hemostatic powder achieved initial hemostasis (even in animals with spurting arterial bleeding) with no bowel obstruction or unintended luminal effects, no local or regional particulate effects, no systemic embolic effects, and no systemic coagulopathic effects.

[A case of primary aortoenteric fistula mimicking ulcer bleeding]

Primary aortoenteric fistula (PAEF) is a rare disease with a high mortality rate due to massive hemorrhaging and diagnostic difficulties. Although hemorrhagic regions can be identified by endoscopy, it is difficult to diagnose PAEF by this method. If PAEF is suspected, endoscopic procedure should be terminated and abdominal CT should be performed. Overlooking the herald bleeding of PAEF can lead to massive bleeding and death. An 85-year-old previously healthy male presented with a complaint of melena. Gastrointestinal endoscopy identified a hemorrhagic site in the third portion of the duodenum and endoscopic hemostasis was performed. However, during the procedure, it became apparent that the hemorrhage was probably not the result of a simple duodenal ulceration and abdominal CT was performed immediately. An aortic aneurysm connected to the duodenum was identified, confirming the diagnosis of PAEF. However, the patient died of massive hemorrhaging before an operation could be performed.

Gastric intramural hematoma accompanied by severe epigastric pain and hematemesis after endoscopic mucosal resection

Gastric intramural hematoma is a rare injury of the stomach, and is most often seen in patients with underlying disease. Such injury following endoscopic therapy is even rarer, and there are no universally accepted guidelines for its treatment. In this case report, we describe a gastric intramural hematoma which occurred within 6 h of endoscopic mucosal resection (EMR). Past medical history of this patient was negative, and laboratory examinations revealed normal coagulation profiles and platelet count. Following EMR, the patient experienced severe epigastric pain and vomited 150 mL of gastric contents which were bright red in color. Subsequent emergency endoscopy showed a 4 cm × 5 cm diverticulum-like defect in the anterior gastric antrum wall and a 4 cm × 8 cm intramural hematoma adjacent to the endoscopic submucosal dissection lesion. Following unsatisfactory temporary conservative management, the patient was treated surgically and made a complete recovery. Retrospectively, one possible reason for the patient’s condition is that the arterioles in the submucosa or muscularis may have been damaged during deep and massive submucosal injection. Thus, endoscopists should be aware of this potential complication and improve the level of surgery, especially the skills required for submucosal injection.