A Rare Complication of Endoscopic Epinephrine Injection Therapy for Duodenal Ulcer Bleeding

Changwoo Oh; Tae Ho Kim

doi:10.7704/kjhugr.2024.0071

Question

A 21-year-old male presented with melena and was diagnosed with duodenal ulcer bleeding (1 cm active ulcer, Forrest Ib) at a private clinic (Fig. 1). For patients with peptic ulcer bleeding, endoscopic hemostasis is recommended in case of active bleeding or high risk for rebleeding during upper gastrointestinal endoscopy [1]. After an epinephrine injection for hemostasis, he was referred for further treatment and hospitalization. The usual dose and concentration of injected epinephrine solution is 10–20 mL of 1:10000 epinephrine solution. The patient’s medical history was notable only for allergic rhinitis, with no significant family history. Helicobacter test was performed during endoscopy, and the Helicobacter test was negative. He was a non-smoker and consumed alcohol occasionally.

Upon admission, the patient exhibited melena without other significant symptoms. Vital signs were stable. Initial laboratory tests showed normal ranges for white blood cells (5.77×10⁹/L), hemoglobin (14.7 g/dL), hematocrit (46.2%), platelet count (211×10⁹/L), glucose (86 mg/dL), BUN/Cr (10.2/0.96 mg/dL), total protein (7.3 g/dL), albumin (4.6 g/dL), AST/ALT (15/5 U/L), alkaline phosphatase (64 U/L), r-GTP (12 U/L), total bilirubin (0.56 mg/dL), and electrolytes (Na/K 140/4.2 mEq/L).

On the evening of admission, the patient developed epigastric and right upper quadrant pain accompanied by bile-colored vomiting. Follow-up complete blood count showed elevated WBC (15.37×10⁹/L with 88.5% neutrophils), hemoglobin (13.4 g/dL), and platelet count (210×10⁹/L). Biochemical tests revealed elevated amylase (1157 U/L) and lipase (1914 U/L) levels, with normal bilirubin levels (T-bil/D-bil 0.39/0.24 mg/dL).

Endoscopic evaluation (Fig. 2) and abdominal computed tomography (CT) scan (Fig. 3) were performed.

What is the most likely diagnosis and treatment policy?

Answer

Duodenal intramural hematoma is a rare condition, generally occurring in about 80% of cases due to blunt abdominal trauma. This is because the second part of the duodenum is located in front of the vertebra and has a rich submucosal vascular supply. It primarily occurs in individuals under the age of 15 and is rarely reported in adults. In addition to blunt abdominal trauma, it can also rarely occur as a complication of anticoagulation therapy, blood dyscrasia, pancreatic disease, and collagen vascular disease [2].

Similar to the case presented here, duodenal hematoma following a diagnostic duodenal biopsy is rarely reported. Symptoms of duodenal intramural hematoma depend on the location, size, and patient of the hematoma. And symptoms vary depending on the overall condition of the body. Symptoms caused by duodenal obstruction. It is mainly accompanied by abdominal pain, nausea, and vomiting, but rarely causes pain in the pancreatic duct or complications such as secondary pancreatitis and cholangitis occur due to bile duct obstruction [3-5].

For diagnosis, imaging tests such as abdominal CT scan or abdominal sonography are required, along with laboratory evaluations including amylase and lipase. Abdominal examination findings often show signs of peritoneal irritation [6].

He developed severe epigastric pain and elevated amylase/lipase approximately 12 hours after endoscopic epinephrine submucosal injection. Emergency endoscopic examination and CT confirmed the diagnosis of acute pancreatitis due to submucosal duodenal hematoma. Conservative management for pancreatitis was initiated, leading to gradual symptom improvement. However, a persistent hematoma was noted on a follow-up abdominal CT scan three weeks later (Fig. 4), necessitating percutaneous pigtail insertion for hematoma drainage. Two months after hospitalization, he was discharged with improved condition. Eight months after admission, subsequent clinical and imaging findings showed significant improvement (Fig. 5).

There are no clear principles for treatment yet, but most cases are treated with conservative therapy such as fasting and gastric decompression with L-tube. However, if there are complications such as severe pancreatitis, intestinal perforation, or peritonitis, or there is no improvement in conservative treatment, surgical therapy should be considered. In this case, it was successfully treated with percutaneous hematoma drainage and conservative care for acute pancreatitis [7].

This case highlights a rare but serious complication of endoscopic epinephrine injection for duodenal ulcer bleeding. The development of a submucosal hematoma can result in acute pancreatitis, requiring prompt recognition and appropriate management. This case underscores the importance of monitoring for potential complications following endoscopic interventions.

Notes

Availability of Data and Material

Data sharing not applicable to this article as no datasets were generated or analyzed during the study.

Conflicts of Interest

Tae Ho Kim, a contributing editor of the Korean Journal of Helicobacter and Upper Gastrointestinal Research, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.

Funding Statement

None

Acknowledgements

None

Authors’ Contribution

Conceptualization: Tae Ho Kim. Data curation: Tae Ho Kim. Formal analysis: Changwoo Oh. Investigation: Tae Ho Kim. Methodology: Tae Ho Kim. Project administration: Tae Ho Kim. Resources: Tae Ho Kim. Software: Changwoo Oh. Supervision: Tae Ho Kim. Validation: Tae Ho Kim. Visualization: Changwoo Oh. Writing—original draft: Changwoo Oh. Writing—review & editing: Tae Ho Kim. Approval of final manuscript: all authors.

Ethics Statement

The requirement for informed consent was waived because of the low risk nature of this report.

Fig. 1.

Initial endoscopic images of private clinic showed acute duodenal ulcer with hematoma on the base (A). Endoscopic hemostasis with epinephrine injection was performed (B).

Fig. 2.

Endoscopic images showed luminal narrowing of duodenum’s second portion due to external compression with submucosal hematoma (A and B).

Fig. 3.

On hospital day 2, abdominal computed tomography scan revealed a large submucosal hematoma in the duodenum (blue arrows).

Fig. 4.

Persistent hematoma was noted on a follow-up abdominal computed tomography scan three weeks later.

Fig. 5.

After 8 months, follow up abdominal computed tomography showed disappearance of hematoma.

REFERENCES

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