Intramural Duodenal Haematoma After Upper Gastrointestinal Endoscopic Biopsy in a Bone Marrow Transplant Recipient

Intraduodenal haematoma (IDH) has been noted usually after blunt abdominal trauma. It has been recognized as a complication of endoscopic biopsy and the risk is high in patients with bleeding disorders. History of bone marrow transplantation seems to be relevant risk factor. The incidence is estimated to be 1/1250 upper gastrointestinal endoscopies. The diagnosis is likely if symptoms of acute abdominal pain and vomiting occur within 48 hours after duodenal biopsy. The symptoms are usually caused by duodenal obstruction. Pancreatitis may develop. Conservative management is the preferred approach if perforation is excluded. Complete resolution generally occurs within 2-3 weeks. 

A-18-year old girl with acute lymphoblastic leukemia underwent allogeneic peripheral blood stem cell transplantation. Diarrhea developed on the third month and gastrointestinal endoscopic biopsies were performed for GVHD evaluation. The mucosa of stomach was reddish and edematous but other parts looked normal. Three hours later the patient had severe vomiting, intense abdominal tenderness and massive haematemesis which required red cell transfusions.  A second look revealed active hemorrhage from biopsy side at the cardioesophageal junction. Epinephrine injection was performed and the clinical status was related to Mallory-Weiss tear due to severe vomiting. However her complaints persisted despite full supportive treatment. Abdominal CT scan revealed a 9 cm mass with diameter of 5 cm within the second and third duodenal portions consistent with an intramural haematoma. There was also  hemoperitoneum. Since perforation was excluded conservative management was initiated including bowel rest, parenteral nutrition and nasogastric decompression. On day 14 serum bilirubin levels reached 7.5 mg/dl with GGT:393 U/L, ALP:329 U/L values. MRI revealed 8x4 cm haematoma compressing the ampulla of Vater. She improved in the following days. Haematoma regressed to 3 cm on the 4th week and the patient was discharged.

In our patient blood counts and coagulation tests were within normal limits at the time of endoscopic intervention. Biopsies were consistent with GVHD and the mucosal damage caused by this condition may have been contributed to duodenal vulnerability. Depending on other reported cases with bone marrow transplantation we can conclude that endoscopic interventions should be carefully employed in this subgroup of patients.