Intraduodenal and retroperitoneal hematoma after duodenal biopsies

Introduction

Intramural duodenal haematomas (IDH) are infrequent lesions that are usually seen in children after blunt abdominal trauma or in patients with underlying risk factors such as coagulation disorders or anticoagulant therapy[1],[2]. They can also, but rarely, occur as a complication of endoscopic diagnostic and therapeutic procedures, even in the absence of these risk factors[2],[3].

Clinical case

The patient was a 20-year-old male with no previous history of interest who began an outpatient study due to abdominal pain and chronic diarrhoea, for which reason oral endoscopy was performed and duodenal biopsies were taken with standard forceps. However, approximately 8-12 hours after the endoscopy, he began to experience intense epigastralgia which required an urgent abdominal CT scan and a collection measuring 12 x 6 x 10 cm compatible with haematoma was found in the duodenum and right retroperitoneum. During hospitalisation, an abdominal ultrasound scan was performed (Figure 1) with views to subsequent check-ups. A conservative treatment was decided in conjunction with surgery and the clinical, analytical and ultrasound evolution was favourable with this treatment. Finally, he was assessed by haematology, ruling out haematological disease or underlying coagulation disorder.

Figure 1

A and B correspond to ultrasound images obtained during admission where a dilated gastric chamber is identified, as well as a mass with heterogeneous and hyperechogenic content, bean-shaped morphology and caudal location to the pancreas compatible with retroperitoneal haematoma. C and D are the outpatient controls after discharge where the haematoma is no longer identified.

Discussion

Upper endoscopy is a common procedure with few complications, most commonly bleeding, perforation and sedation-related complications, with the occurrence of IDH being very rare[2]. Traction of the duodenal mucosa with the endoscopic forceps during biopsy may separate a considerable area of the duodenal mucosa from the duodenal wall, tearing the intramural vessels. Therefore, it has been suggested that the endoscopic forceps should not be advanced more than 3 cm beyond the tip of the endoscope to grasp the mucosa in order to minimise shearing[2],[4].

Symptoms of IDH include abdominal pain and vomiting which usually appear within 48 hours of biopsies, although they can appear up to seven days later[1],[2]. It can also lead to cholestasis or acute pancreatitis due to obstruction of the duodenal papilla[1].

Laboratory findings are non-specific and show decreased haemoglobin concentration[1]. A summary diagnosis can be made by imaging (ultrasound, CT or MRI) or endoscopy[1],,[2]. Ultrasound findings are variable and include a thickened hypoechogenic duodenal wall, a mass close to the duodenum of variable echogenicity, a paravertebral cystic lesion simulating a pancreatic pseudocyst and a polypoid lesion within a distended loop of bowel, sometimes making it difficult to diagnose this entity by this technique. In addition, the echogenicity of the haematoma changes substantially over time and may resemble an abscess, showing internal echoes in some cases[3],[5]. However, once the diagnosis has been made, ultrasound may be used for the follow-up of patients with IDH, as it is available in most centres and avoids the use of ionising radiation[1],[5].

Treatment is conservative in most cases, consisting of fasting, serotherapy and nasogastric aspiration[1],[2], with resolution of IDH occurring one to three weeks after onset[1],[6]. In the event of perforation or lack of improvement with conservative management, surgery is indicated[1],[2].