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

Abstract

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.

A Rare Case of Gastric Intramural Hematoma in Recurrent Leukemia

“…Spontaneous intramural hematoma of the stomach without an identifiable cause has been reported in the literature as well [7]. One of the main etiologies of gastric intramural hematomas is that of procedure-related cases, including argon plasma coagulation (APC), endoscopic mucosal resection (EMR), EUS-guided fine needle aspiration (EUS-FNA), extracorporeal shock wave lithotripsy (ESWL), percutaneous endoscopic gastrostomy (PEG), and postinjection therapy [6,[8][9][10][11][12][13]. Other causes include the use of anticoagulants [14], ulcer disease [11], amyloidosis [15], and pancreatitis [16], or even in the setting of infection [17].…”

“…In the stomach wall, the arteries and veins are arranged side by side and distributed in a mesh-like pattern with a significant number of blood vessels in the submucosal layer [ 5 ]. The shredding of terminal arteries at the point of leaving the mesentery and penetrating the muscular layer with subsequent dissection of the muscularis propria from the submucosa leads to hematoma formation in the submucosal or muscular layer [ 1 , 6 ].…”

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

“…It can arise in the submucosal or muscular layer of the organ [ 4 ]. The postulated mechanism for the bleeding is shredding of terminal arteries at the point of penetration in the muscular layer with subsequent dissection of the muscularis propria from the submucosa [ 5 , 6 ] and the most common contributing factor is hemorrhagic diathesis/anticoagulant use [ 7 ].…”

“…The endoscopy-related cases include post-percutaneous endoscopic gastrostomy (PEG), argon plasma coagulation (APC), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), EUS-guided fine needle aspiration (EUS-FNA) and post-injection therapy [ 6 , 7 , [14] , [15] , [16] , [17] , [18] , [19] ]. Furthermore, there are few reports with anedoctal causes for GIH, such as foreign body, peptic ulcer disease, amyloidosis and pancreatitis [ [20] , [21] , [22] , [23] , [24] ].…”

“…It is especially recommended in cases with unclear diagnosis, suspected complications, ongoing bleeding and failure of minimally invasive therapy [ 5 , 25 , 28 , 29 ]. The decision to operate emergently is largely driven by the clinical scenario [ 6 ].…”