Intraoperative Gastric Intramural Hematoma: A Rare Complication of Percutaneous Endoscopic Gastrostomy

Abstract

Patient: Male, 73Final Diagnosis: Gastric intramural hematomaSymptoms: BleedingMedication: —Clinical Procedure: Percutaneous endoscopic gastrostomySpecialty: Gastroenterology and HepatologyObjective:Diagnostic/therapeutic accidentBackground:Intramural hematomas primarily present in the esophagus or duodenum. We report a case of intramural hematoma in the gastric wall (GIH) secondary to percutaneous endoscopic gastrostomy (PEG) tube placement in a setting of platelet dysfunction.Case Report:This case study reviews the hospitalization of a 73-year-old male with a history of chronic kidney disease who was admitted for coronary artery bypass graft surgery and mitral valve repair. During his complicated hospital course, he inadvertently required the placement of a PEG tube. His coagulation profile prior to this procedure was within normal limits. The patient had no history of coagulopathy and was taking aspirin 81 mg per day. PEG tube placement was withheld due to an expanding hematoma that was noted at the site of needle insertion in the gastric wall. A single dose of intravenous desmopressin (0.3 microgram/kilogram) was administered under the suspicion of uremic bleeding. No further gastrointestinal bleeding events were observed. A platelet function assay (PFA) and collagen/epinephrine closure time indicated platelet dysfunction. Three days later, we again attempted a PEG tube placement. His PFA prior to this procedure had normalized due to aspirin discontinuation and improvement of renal function. Esophagogastroduodenoscopy (EGD) showed an area of flat bluish gastric submucosal bruising at the site of the previous hematoma. The PEG tube was placed successfully at an adjacent site. Over the course of the following month, the patient underwent uneventful feeding through the PEG tube.Conclusions:To our knowledge, cases of GIH are rarely documented in literature. Multidisciplinary vigilance is required to maintain a high index of suspicion for this complication in patients with uremia or other coagulopathies to aid in prompt diagnosis.

Intramural duodenal hematoma: clinical course and imaging findings

“…Intramural hematomas of the vessel walls are common (1,2), but they can also occur in the intestinal wall anywhere in the gastrointestinal tract (3–7). Here, clinical signs and symptoms are remarkably different.…”

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].…”

Submucosal hematoma with a wide range of lesions, severe condition and atypical clinical symptoms: A case report

“…SH of digestive tract is rare, and it primarily occurs in the esophagus or duodenum[ 5 ]. In the present case, SH was found extending from the hypopharynx to the lower esophagus.…”