ORIGINAL ARTICLE: GASTROENTEROLOGY
Duodenal Hematoma Following EGD: Comparison With Blunt Abdominal Trauma–Induced Duodenal Hematoma
Benjamin Sahn, ySudha A. Anupindi, zNeha J. Dadhania, Judith R. Kelsen, § Michael L. Nance, and Petar Mamula
ABSTRACT Background: Duodenal hematoma (DH) is a rare complication of esophagogastroduodenoscopy (EGD) with duodenal biopsy and uncommon, but better described following blunt abdominal trauma (BAT). We aimed to describe DH incidence and investigate risk factors for DH development postEGD and compare its features to those post-BAT. Methods: Multiple electronic databases were searched for the diagnosis of DH from 2000 to 2012. Inclusion criteria were patients 0 to 21 years of age who developed a DH following EGD with biopsy or BAT. Exclusion criteria were DH secondary to any other mechanism, EGD performed at another medical center, and insufficient information in the electronic medical record to determine treatments or outcomes. Results: A total of 14 post-EGD and 15 post-BAT patients with DH were included in the study. There were 26,905 EGDs with duodenal biopsies performed during the study period, for an incidence of 1:1922 procedures. Thirteen of 14 (93%) post-EGD DH events occurred between 2007 and 2012 (P < 0.001). The proportion of procedures performed under general anesthesia versus moderate sedation, and performed in the supine position versus left lateral decubitus were close to but did not reach statistical significance. DH-related complications and time to hematoma resolution was similar between groups. Conclusions: In a 13-year study period, 14 patients developed DH after EGD, for an incidence of 1:1922. Method of sedation and supine positioning of the patient during endoscopy warrant further investigation as potential risks. The clinical course and time to recovery with conservative management are similar between patients with EGD and BAT-induced DH. Key Words: blunt abdominal trauma, duodenal hematoma, endoscopic adverse event
hematoma (DH) is a rare complication of EGD with an unknown incidence, but seems to occur much more in children than in adults based on available case reports (3–5). The reasoning for this agerelated discrepancy is unclear. The hypothesized risk factors for postbiopsy DH include the duodenum anatomy, shearing forces generated by grasp biopsy forceps, and underlying medical conditions such as leukemia, bone marrow transplant (BMT) recipient, and coagulopathies (5–8). The majority of pediatric cases reported in the literature have been without these underlying medical disorders, leaving other risk factors a matter of additional speculation. In contrast to the rarity of DH after EGD, DHs are well described as a result of blunt abdominal trauma (BAT) (9–11). The etiology of DH in this setting is mechanical; typically the duodenum is subjected to anterior traumatic force and compression against the vertebral spine posteriorly. The most common sources of trauma in children causing duodenal injury include nonaccidental trauma and motor vehicle accidents (12). Secondary complications and the time course to recovery of DH following EGD or BAT have been previously reported, although not compared directly. The primary aim of this study is to determine the incidence of DH in children following EGD with biopsy. Secondary aims were to investigate additional potential risk factors for the development of DH postendoscopic biopsy, report the clinical presentation and radiological modalities used in a cohort of patients with DH, and compare the clinical course of patients with DH post-EGD to those following BAT.
METHODS (JPGN 2015;60: 69–74)
E
sophagogastroduodenoscopy (EGD) with biopsy is associated with a low risk of complications. Potential EGD adverse events commonly discussed when obtaining informed consent, and described in the literature, include bleeding and perforation (1,2). Postmucosal biopsy bleeding can occur as intraluminal hemorrhage or intramural hematoma. Intramural duodenal
Received May 28, 2014; accepted September 5, 2014. From the Division of Gastroenterology, Hepatology & Nutrition, the yDepartment of Radiology, The Children’s Hospital of Philadelphia, the zDrexel University College of Medicine, and the §Department of General Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA. Address correspondence and reprint requests to Benjamin Sahn, MD, MS, Children’s Medical Center, New Hyde Park, NY 11040 (e-mail: [email protected]). The authors report no conflicts of interest. Copyright # 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000564
JPGN
Volume 60, Number 1, January 2015
Case Acquisition Approval was obtained from our institutional review board before initiation of the study. We conducted a retrospective chart review of confirmed cases of DH following either EGD with biopsy or BAT, between January 1, 2000, and December 31, 2012. Cases of DH following EGD were identified by multiple search mechanisms. First, each of the presently attending and fellow physicians and clinical nurse practitioners in the Division of Gastroenterology, Hepatology, & Nutrition (The Children’s Hospital of Philadelphia) were contacted directly to recall any cases, which identified 6. Then the present electronic medical record (EMR) was searched for multiple possible International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, and our radiology database was searched for all studies with the key words duodenum and hematoma in the same final report. For those cases post-EGD, these additional searches identified the same 6 reported by recall and 8 more for a total of 14 cases. To identify the patients with DH post-BAT, our institutional trauma registry was queried for DH, identifying 12 cases. The EMR and radiology databases were then searched as above, finding the same 12 cases, and yielded 5 additional for a total of 17 trauma cases identified initially.
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Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Sahn et al
JPGN
Endoscopes and Biopsy Forceps All but 1 endoscopy were performed with standard size Olympus GIF series 140–180 gastroscopes (Olympus). The outer diameters (ODs) of the gastroscopes used were 8.6 mm (GIF-160), 8.8 mm (GIF-180), or 9.8 mm (GIF-140). In 1 patient weighing 20,000 nontherapeutic EGDs (with or without duodenal biopsy) (13). Although it is standard practice to inform caregivers and patients about perforation risk, mention of potential DH specifically may not be as commonplace, yet may occur as much as 10-fold more frequently than perforation during a diagnostic EGD with biopsies. The available literature on DH as a complication of EGD with biopsy is exclusively in the form of case reports, making the incidence of DH in children to this point undefined. One review has previously approximated an incidence of 1:1250 based on 2 DH cases for a 5-year period (3). Our report is the first case series of >3 DH cases following EGD from a single center, and the first to report an incidence for such an extended time period. In the previous reports on this clinical condition, the proposed risk factors receiving the most focus have been the anatomy of the duodenum (retroperitoneal fixed position, adjacency to the spine, and robust vascularity of the submucosa), shearing and tenting forces applied to the mucosa and submucosa during biopsy acquisition, and patient conditions of coagulopathy, history of leukemia, or BMT (4–7,14). In our review, 29% of the EGD cohort had history of any transplant, including 2 liver and 1 heart transplant, in addition to the 1 BMT. Previously, Dunkin et al (15) published 3 cases, which included 1 liver and 1 small bowel transplant recipient. Our report provides further evidence for speculation to whether any organ transplant, and not just BMT, increases the risk of DH. Three of our patients (23%) were taking anticoagulants; 2 were taking aspirin and 1 enoxaparin. Both patients taking aspirin were previous organ transplant recipients. Although aspirin is considered low risk and not routinely necessary to discontinue before diagnostic EGD, according to guidelines published by the American Society of Gastrointestinal Endoscopy Standards of Practice Committee on use of anticoagulation and endoscopy (16), its use may deserve additional consideration when other bleeding risk factors are present, or in posttransplant patients. We are interested in finding that all but 1 post-EGD DH event occurred between 2007 and 2012, which was statistically significant. In addition to this, the large majority during that time period had their EGD performed under GA, which trended toward, but did not reach, statistical significance. One variable we considered related to this finding was body positioning, given most under GA in this cohort were supine, and left lateral decubitus is the default positioning for EGD. Although this did not reach statistical significance, the relatively small sample size may have been a limiting factor. It was not possible to identify the body positioning www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 60, Number 1, January 2015
for all EGDs performed during the study period, precluding the calculation of a ratio of DH events to each body position. The possibility that greater shearing forces are applied to the mucosa while the patient is supine, as the endoscope traverses the duodenal C-loop, or during biopsy sampling, remains hypothetical but worth further attention. Overall, experience level of the endoscopist did not have a clear impact, as 8 procedures were performed by a fellow and 6 by an attending. One fellow, however, did perform 2 of the procedures, and 2 senior attending physicians each had 2 DH events occur. This may suggest the importance of an individual’s technique in DH development, 1 such example being a longer distance of forceps extension beyond the tip of the endoscope, described by previous authors (5,7,17). The particular biopsy forceps model used in each case could not be determined, limiting any conclusion about type of forceps model and associated DH events. Abdominal pain and vomiting were expected given the type of lesion and were the most common presenting complaints. Only 1 patient presented >72 hours after EGD, who experienced the preexisting conditions of static encephalopathy and cerebral palsy, making identification of early symptoms more difficult. The same timing for symptoms onset was found in the 15 children with DH secondary to BAT, with all but 1 patient presenting within 72 hours of trauma. These data suggest that abdominal pain or vomiting that first develops >72 hours after EGD or blunt trauma is unlikely secondary to a DH. Ultrasound, CT, and UGI studies using water soluble or barium contrast were effectively used to diagnose and serially study patients with DH in our study. US is advantageous because it is noninvasive and does not use ionizing radiation; however, it is operator dependent. We agree with previously published recommendations to consider US for initial diagnosis of suspected DH following EGD in stable patients and CT in unstable patients, followed by US as the modality of choice for follow-up surveillance (15). In cases of trauma, CT provides excellent cross-sectional detail and can identify additional injuries. Oral contrast is not commonly used in the setting of trauma across many centers because it delays time to scanning, has been shown not to benefit in evaluation of bowel injuries, and there is a low but potential risk of perforation (18). High sensitivity and specificity of CT over US in evaluation of BAT in children have been described (19,20). A full discussion comparing CT and US for trauma is beyond the scope of this discussion. US, however, does not presently have a role in the initial evaluation of intestinal injury due to BAT; rather CT is most appropriate, especially when multiple injuries are suspected. Except for 1 patient with BAT, all of the others required inpatient hospitalization. Concurrent pancreatitis and/or acute symptomatic anemia occurred in a similar proportion of the EGD and BAT patient groups. In the EGD group, 4/14 developed biliary obstruction, whereas none of the BAT group did. There was no clear difference in the location of the lesion within the duodenum between the 2 groups to suggest that DH post-EGD is more likely to cause biliary obstruction. We suspect this difference is more likely related to the small sample size. The necessity for TPN or jejunal feedings owing to a prolonged period of nil per os was also similar between both groups. Overall, the clinical course of the 2 groups was similar. In all of the 29 cases combined, the DH resolved spontaneously with conservative management; no intervention other than nutritional support was needed while allowing time for natural resolution. Various interventional techniques to treat refractory intramural DHs have been described including surgical evacuation (3,21), US-guided drainage (22), and an adult who underwent endoscopic incision and drainage (23). The length of hospital stay www.jpgn.org
Duodenal Hematoma Following EGD was similar between EGD and BAT groups. Many in the trauma cohort sustained additional minor or major injuries, yet time to resolution of the DH was the limiting factor for continued hospitalization in many of them. The limitations of this study are mostly related to its retrospective nature. The retrospective study makes determining the incidence and true risk factors for this complication imprecise. It is possible that patients could have developed a DH after endoscopy but presented to another hospital for treatment and did not follow up at our center, although we believe this to be unlikely. There could have been additional cases in either cohort and not identified by our chart review, although we minimized this possibility by using multiple patient search mechanisms. Presenting symptoms could only be determined from the available chart documentation, making undocumented additional symptoms possible. Furthermore, we were unable to identify the number of patients out of the approximately 27,000 undergoing EGD who had a potential risk factor and did not develop a DH, such as anticoagulant use or prior transplant, thereby limiting our statistical analysis of risk.
CONCLUSIONS In a 13-year period, 14 diagnostic EGDs with duodenal biopsy complicated by DH were identified, for an incidence of 1:1922 procedures. The use of anticoagulants, including aspirin, and being a transplant recipient of any kind may be risk factors associated with development of DH post-EGD. Method of sedation and supine positioning of the patient during endoscopy warrant further investigation in future reviews or prospective studies. Despite significant force associated with the development of a DH following BAT in comparison to endoscopy, both patient groups have similar clinical courses and time to recovery with conservative management.
REFERENCES 1. Thakkar K, El-Serag HB, Mattek N, et al. Complications of pediatric EGD: a 4-year experience in PEDS-CORI. Gastrointest Endosc 2007; 65:213–21. 2. Iqbal CW, Askegard-Giesmann JR, Pham TH, et al. Pediatric endoscopic injuries: incidence, management, and outcomes. J Pediatr Surg 2008;43:911–5. 3. Guzman C, Bousvaros A, Buonomo C, et al. Intraduodenal hematoma complicating intestinal biopsy: case reports and review of the literature. Am J Gastroenterol 1998;93:2547–50. 4. Diniz-Santos DR, de Andrade Cairo RC, Braga H, et al. Duodenal hematoma following endoscopic duodenal biopsy: a case report and review of the existing literature. Can J Gastroenterol 2006;20:39–42. 5. Grasshof C, Wolf A, Neuwirth F, et al. Intramural duodenal haematoma after endoscopic biopsy: case report and review of the literature. Case Rep Gastroenterol 2012;6:5–14. 6. Szajewska H, Albrecht P, Ziolkowski J, et al. Intramural duodenal hematoma: an unusual complication of duodenal biopsy sampling. J Pediatr Gastroenterol Nutr 1993;16:331–3. 7. Zinelis SA, Hershenson LM, Ennis MF, et al. Intramural duodenal hematoma following upper gastrointestinal endoscopic biopsy. Dig Dis Sci 1989;34:289–91. 8. Hameed S, McHugh K, Shah N, et al. Duodenal haematoma following endoscopy as a marker of coagulopathy. Pediatr Radiol 2014;44:392– 7. 9. Gutierrez IM, Mooney DP. Operative blunt duodenal injury in children: a multi-institutional review. J Pediatr Surg 2012;47:1833–6. 10. Shilyansky J, Pearl RH, Kreller M, et al. Diagnosis and management of duodenal injuries in children. J Pediatr Surg 1997;32:880–6. 11. Thoms CA, Ricketts RR. Intramural duodenal hematoma in children: reappraisal of current management. South Med J 1988;81:985–8. 12. Clendenon JN, Meyers RL, Nance ML, et al. Management of duodenal injuries in children. J Pediatr Surg 2004;39:964–8.
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Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Sahn et al 13. Hsu EK, Chugh P, Kronman MP, et al. Incidence of perforation in pediatric GI endoscopy and colonoscopy: an 11-year experience. Gastrointest Endosc 2013;77:960–6. 14. Ramakrishna J, Treem WR. Duodenal hematoma as a complication of endoscopic biopsy in pediatric bone marrow transplant recipients. J Pediatr Gastroenterol Nutr 1997;25:426–9. 15. Dunkin D, Benkov KJ, Rosenberg HK. Duodenal and rectal hematomas complicating endoscopic biopsy: use of sonography in pediatrics. J Ultrasound Med 2009;28:1575–80. 16. ASGE Standards of Practice Committee, Anderson MA, BenMenachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009;70:1060–70. 17. Camarero C, Herrera D, Corbaton J, et al. Intramural haematoma of the duodenum following endoscopic biopsy: an unusual complication of non-therapeutic endoscopy in children. Eur J Pediatr 2004;163:418–9.
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18. Lee CH, Haaland B, Earnest A, et al. Use of positive oral contrast agents in abdominopelvic computed tomography for blunt abdominal injury: meta-analysis and systematic review. Eur Radiol 2013;23:2513–21. 19. Strouse PJ, Close BJ, Marshall KW, et al. CT of bowel and mesenteric trauma in children. Radiographics 1999;19:1237–50. 20. Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008;43:72–82. 21. Lipson SA, Perr HA, Koerper MA, et al. Intramural duodenal hematoma after endoscopic biopsy in leukemic patients. Gastrointest Endosc 1996;44:620–3. 22. Lloyd GM, Sutton CD, Marshall LJ, et al. Case of duodenal haematoma treated with ultrasound guided drainage. ANZ J Surg 2004;74:500–1. 23. Kwon CI, Ko KH, Kim HY, et al. Bowel obstruction caused by an intramural duodenal hematoma: a case report of endoscopic incision and drainage. J Korean Med Sci 2009;24:179–83.
www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Duodenal Hematoma Following EGD: Comparison With Blunt Abdominal Trauma–Induced Duodenal Hematoma
Benjamin Sahn, ySudha A. Anupindi, zNeha J. Dadhania, Judith R. Kelsen, § Michael L. Nance, and Petar Mamula
ABSTRACT Background: Duodenal hematoma (DH) is a rare complication of esophagogastroduodenoscopy (EGD) with duodenal biopsy and uncommon, but better described following blunt abdominal trauma (BAT). We aimed to describe DH incidence and investigate risk factors for DH development postEGD and compare its features to those post-BAT. Methods: Multiple electronic databases were searched for the diagnosis of DH from 2000 to 2012. Inclusion criteria were patients 0 to 21 years of age who developed a DH following EGD with biopsy or BAT. Exclusion criteria were DH secondary to any other mechanism, EGD performed at another medical center, and insufficient information in the electronic medical record to determine treatments or outcomes. Results: A total of 14 post-EGD and 15 post-BAT patients with DH were included in the study. There were 26,905 EGDs with duodenal biopsies performed during the study period, for an incidence of 1:1922 procedures. Thirteen of 14 (93%) post-EGD DH events occurred between 2007 and 2012 (P < 0.001). The proportion of procedures performed under general anesthesia versus moderate sedation, and performed in the supine position versus left lateral decubitus were close to but did not reach statistical significance. DH-related complications and time to hematoma resolution was similar between groups. Conclusions: In a 13-year study period, 14 patients developed DH after EGD, for an incidence of 1:1922. Method of sedation and supine positioning of the patient during endoscopy warrant further investigation as potential risks. The clinical course and time to recovery with conservative management are similar between patients with EGD and BAT-induced DH. Key Words: blunt abdominal trauma, duodenal hematoma, endoscopic adverse event
hematoma (DH) is a rare complication of EGD with an unknown incidence, but seems to occur much more in children than in adults based on available case reports (3–5). The reasoning for this agerelated discrepancy is unclear. The hypothesized risk factors for postbiopsy DH include the duodenum anatomy, shearing forces generated by grasp biopsy forceps, and underlying medical conditions such as leukemia, bone marrow transplant (BMT) recipient, and coagulopathies (5–8). The majority of pediatric cases reported in the literature have been without these underlying medical disorders, leaving other risk factors a matter of additional speculation. In contrast to the rarity of DH after EGD, DHs are well described as a result of blunt abdominal trauma (BAT) (9–11). The etiology of DH in this setting is mechanical; typically the duodenum is subjected to anterior traumatic force and compression against the vertebral spine posteriorly. The most common sources of trauma in children causing duodenal injury include nonaccidental trauma and motor vehicle accidents (12). Secondary complications and the time course to recovery of DH following EGD or BAT have been previously reported, although not compared directly. The primary aim of this study is to determine the incidence of DH in children following EGD with biopsy. Secondary aims were to investigate additional potential risk factors for the development of DH postendoscopic biopsy, report the clinical presentation and radiological modalities used in a cohort of patients with DH, and compare the clinical course of patients with DH post-EGD to those following BAT.
METHODS (JPGN 2015;60: 69–74)
E
sophagogastroduodenoscopy (EGD) with biopsy is associated with a low risk of complications. Potential EGD adverse events commonly discussed when obtaining informed consent, and described in the literature, include bleeding and perforation (1,2). Postmucosal biopsy bleeding can occur as intraluminal hemorrhage or intramural hematoma. Intramural duodenal
Received May 28, 2014; accepted September 5, 2014. From the Division of Gastroenterology, Hepatology & Nutrition, the yDepartment of Radiology, The Children’s Hospital of Philadelphia, the zDrexel University College of Medicine, and the §Department of General Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA. Address correspondence and reprint requests to Benjamin Sahn, MD, MS, Children’s Medical Center, New Hyde Park, NY 11040 (e-mail: [email protected]). The authors report no conflicts of interest. Copyright # 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000564
JPGN
Volume 60, Number 1, January 2015
Case Acquisition Approval was obtained from our institutional review board before initiation of the study. We conducted a retrospective chart review of confirmed cases of DH following either EGD with biopsy or BAT, between January 1, 2000, and December 31, 2012. Cases of DH following EGD were identified by multiple search mechanisms. First, each of the presently attending and fellow physicians and clinical nurse practitioners in the Division of Gastroenterology, Hepatology, & Nutrition (The Children’s Hospital of Philadelphia) were contacted directly to recall any cases, which identified 6. Then the present electronic medical record (EMR) was searched for multiple possible International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, and our radiology database was searched for all studies with the key words duodenum and hematoma in the same final report. For those cases post-EGD, these additional searches identified the same 6 reported by recall and 8 more for a total of 14 cases. To identify the patients with DH post-BAT, our institutional trauma registry was queried for DH, identifying 12 cases. The EMR and radiology databases were then searched as above, finding the same 12 cases, and yielded 5 additional for a total of 17 trauma cases identified initially.
69
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Sahn et al
JPGN
Endoscopes and Biopsy Forceps All but 1 endoscopy were performed with standard size Olympus GIF series 140–180 gastroscopes (Olympus). The outer diameters (ODs) of the gastroscopes used were 8.6 mm (GIF-160), 8.8 mm (GIF-180), or 9.8 mm (GIF-140). In 1 patient weighing 20,000 nontherapeutic EGDs (with or without duodenal biopsy) (13). Although it is standard practice to inform caregivers and patients about perforation risk, mention of potential DH specifically may not be as commonplace, yet may occur as much as 10-fold more frequently than perforation during a diagnostic EGD with biopsies. The available literature on DH as a complication of EGD with biopsy is exclusively in the form of case reports, making the incidence of DH in children to this point undefined. One review has previously approximated an incidence of 1:1250 based on 2 DH cases for a 5-year period (3). Our report is the first case series of >3 DH cases following EGD from a single center, and the first to report an incidence for such an extended time period. In the previous reports on this clinical condition, the proposed risk factors receiving the most focus have been the anatomy of the duodenum (retroperitoneal fixed position, adjacency to the spine, and robust vascularity of the submucosa), shearing and tenting forces applied to the mucosa and submucosa during biopsy acquisition, and patient conditions of coagulopathy, history of leukemia, or BMT (4–7,14). In our review, 29% of the EGD cohort had history of any transplant, including 2 liver and 1 heart transplant, in addition to the 1 BMT. Previously, Dunkin et al (15) published 3 cases, which included 1 liver and 1 small bowel transplant recipient. Our report provides further evidence for speculation to whether any organ transplant, and not just BMT, increases the risk of DH. Three of our patients (23%) were taking anticoagulants; 2 were taking aspirin and 1 enoxaparin. Both patients taking aspirin were previous organ transplant recipients. Although aspirin is considered low risk and not routinely necessary to discontinue before diagnostic EGD, according to guidelines published by the American Society of Gastrointestinal Endoscopy Standards of Practice Committee on use of anticoagulation and endoscopy (16), its use may deserve additional consideration when other bleeding risk factors are present, or in posttransplant patients. We are interested in finding that all but 1 post-EGD DH event occurred between 2007 and 2012, which was statistically significant. In addition to this, the large majority during that time period had their EGD performed under GA, which trended toward, but did not reach, statistical significance. One variable we considered related to this finding was body positioning, given most under GA in this cohort were supine, and left lateral decubitus is the default positioning for EGD. Although this did not reach statistical significance, the relatively small sample size may have been a limiting factor. It was not possible to identify the body positioning www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 60, Number 1, January 2015
for all EGDs performed during the study period, precluding the calculation of a ratio of DH events to each body position. The possibility that greater shearing forces are applied to the mucosa while the patient is supine, as the endoscope traverses the duodenal C-loop, or during biopsy sampling, remains hypothetical but worth further attention. Overall, experience level of the endoscopist did not have a clear impact, as 8 procedures were performed by a fellow and 6 by an attending. One fellow, however, did perform 2 of the procedures, and 2 senior attending physicians each had 2 DH events occur. This may suggest the importance of an individual’s technique in DH development, 1 such example being a longer distance of forceps extension beyond the tip of the endoscope, described by previous authors (5,7,17). The particular biopsy forceps model used in each case could not be determined, limiting any conclusion about type of forceps model and associated DH events. Abdominal pain and vomiting were expected given the type of lesion and were the most common presenting complaints. Only 1 patient presented >72 hours after EGD, who experienced the preexisting conditions of static encephalopathy and cerebral palsy, making identification of early symptoms more difficult. The same timing for symptoms onset was found in the 15 children with DH secondary to BAT, with all but 1 patient presenting within 72 hours of trauma. These data suggest that abdominal pain or vomiting that first develops >72 hours after EGD or blunt trauma is unlikely secondary to a DH. Ultrasound, CT, and UGI studies using water soluble or barium contrast were effectively used to diagnose and serially study patients with DH in our study. US is advantageous because it is noninvasive and does not use ionizing radiation; however, it is operator dependent. We agree with previously published recommendations to consider US for initial diagnosis of suspected DH following EGD in stable patients and CT in unstable patients, followed by US as the modality of choice for follow-up surveillance (15). In cases of trauma, CT provides excellent cross-sectional detail and can identify additional injuries. Oral contrast is not commonly used in the setting of trauma across many centers because it delays time to scanning, has been shown not to benefit in evaluation of bowel injuries, and there is a low but potential risk of perforation (18). High sensitivity and specificity of CT over US in evaluation of BAT in children have been described (19,20). A full discussion comparing CT and US for trauma is beyond the scope of this discussion. US, however, does not presently have a role in the initial evaluation of intestinal injury due to BAT; rather CT is most appropriate, especially when multiple injuries are suspected. Except for 1 patient with BAT, all of the others required inpatient hospitalization. Concurrent pancreatitis and/or acute symptomatic anemia occurred in a similar proportion of the EGD and BAT patient groups. In the EGD group, 4/14 developed biliary obstruction, whereas none of the BAT group did. There was no clear difference in the location of the lesion within the duodenum between the 2 groups to suggest that DH post-EGD is more likely to cause biliary obstruction. We suspect this difference is more likely related to the small sample size. The necessity for TPN or jejunal feedings owing to a prolonged period of nil per os was also similar between both groups. Overall, the clinical course of the 2 groups was similar. In all of the 29 cases combined, the DH resolved spontaneously with conservative management; no intervention other than nutritional support was needed while allowing time for natural resolution. Various interventional techniques to treat refractory intramural DHs have been described including surgical evacuation (3,21), US-guided drainage (22), and an adult who underwent endoscopic incision and drainage (23). The length of hospital stay www.jpgn.org
Duodenal Hematoma Following EGD was similar between EGD and BAT groups. Many in the trauma cohort sustained additional minor or major injuries, yet time to resolution of the DH was the limiting factor for continued hospitalization in many of them. The limitations of this study are mostly related to its retrospective nature. The retrospective study makes determining the incidence and true risk factors for this complication imprecise. It is possible that patients could have developed a DH after endoscopy but presented to another hospital for treatment and did not follow up at our center, although we believe this to be unlikely. There could have been additional cases in either cohort and not identified by our chart review, although we minimized this possibility by using multiple patient search mechanisms. Presenting symptoms could only be determined from the available chart documentation, making undocumented additional symptoms possible. Furthermore, we were unable to identify the number of patients out of the approximately 27,000 undergoing EGD who had a potential risk factor and did not develop a DH, such as anticoagulant use or prior transplant, thereby limiting our statistical analysis of risk.
CONCLUSIONS In a 13-year period, 14 diagnostic EGDs with duodenal biopsy complicated by DH were identified, for an incidence of 1:1922 procedures. The use of anticoagulants, including aspirin, and being a transplant recipient of any kind may be risk factors associated with development of DH post-EGD. Method of sedation and supine positioning of the patient during endoscopy warrant further investigation in future reviews or prospective studies. Despite significant force associated with the development of a DH following BAT in comparison to endoscopy, both patient groups have similar clinical courses and time to recovery with conservative management.
REFERENCES 1. Thakkar K, El-Serag HB, Mattek N, et al. Complications of pediatric EGD: a 4-year experience in PEDS-CORI. Gastrointest Endosc 2007; 65:213–21. 2. Iqbal CW, Askegard-Giesmann JR, Pham TH, et al. Pediatric endoscopic injuries: incidence, management, and outcomes. J Pediatr Surg 2008;43:911–5. 3. Guzman C, Bousvaros A, Buonomo C, et al. Intraduodenal hematoma complicating intestinal biopsy: case reports and review of the literature. Am J Gastroenterol 1998;93:2547–50. 4. Diniz-Santos DR, de Andrade Cairo RC, Braga H, et al. Duodenal hematoma following endoscopic duodenal biopsy: a case report and review of the existing literature. Can J Gastroenterol 2006;20:39–42. 5. Grasshof C, Wolf A, Neuwirth F, et al. Intramural duodenal haematoma after endoscopic biopsy: case report and review of the literature. Case Rep Gastroenterol 2012;6:5–14. 6. Szajewska H, Albrecht P, Ziolkowski J, et al. Intramural duodenal hematoma: an unusual complication of duodenal biopsy sampling. J Pediatr Gastroenterol Nutr 1993;16:331–3. 7. Zinelis SA, Hershenson LM, Ennis MF, et al. Intramural duodenal hematoma following upper gastrointestinal endoscopic biopsy. Dig Dis Sci 1989;34:289–91. 8. Hameed S, McHugh K, Shah N, et al. Duodenal haematoma following endoscopy as a marker of coagulopathy. Pediatr Radiol 2014;44:392– 7. 9. Gutierrez IM, Mooney DP. Operative blunt duodenal injury in children: a multi-institutional review. J Pediatr Surg 2012;47:1833–6. 10. Shilyansky J, Pearl RH, Kreller M, et al. Diagnosis and management of duodenal injuries in children. J Pediatr Surg 1997;32:880–6. 11. Thoms CA, Ricketts RR. Intramural duodenal hematoma in children: reappraisal of current management. South Med J 1988;81:985–8. 12. Clendenon JN, Meyers RL, Nance ML, et al. Management of duodenal injuries in children. J Pediatr Surg 2004;39:964–8.
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Sahn et al 13. Hsu EK, Chugh P, Kronman MP, et al. Incidence of perforation in pediatric GI endoscopy and colonoscopy: an 11-year experience. Gastrointest Endosc 2013;77:960–6. 14. Ramakrishna J, Treem WR. Duodenal hematoma as a complication of endoscopic biopsy in pediatric bone marrow transplant recipients. J Pediatr Gastroenterol Nutr 1997;25:426–9. 15. Dunkin D, Benkov KJ, Rosenberg HK. Duodenal and rectal hematomas complicating endoscopic biopsy: use of sonography in pediatrics. J Ultrasound Med 2009;28:1575–80. 16. ASGE Standards of Practice Committee, Anderson MA, BenMenachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009;70:1060–70. 17. Camarero C, Herrera D, Corbaton J, et al. Intramural haematoma of the duodenum following endoscopic biopsy: an unusual complication of non-therapeutic endoscopy in children. Eur J Pediatr 2004;163:418–9.
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18. Lee CH, Haaland B, Earnest A, et al. Use of positive oral contrast agents in abdominopelvic computed tomography for blunt abdominal injury: meta-analysis and systematic review. Eur Radiol 2013;23:2513–21. 19. Strouse PJ, Close BJ, Marshall KW, et al. CT of bowel and mesenteric trauma in children. Radiographics 1999;19:1237–50. 20. Bixby SD, Callahan MJ, Taylor GA. Imaging in pediatric blunt abdominal trauma. Semin Roentgenol 2008;43:72–82. 21. Lipson SA, Perr HA, Koerper MA, et al. Intramural duodenal hematoma after endoscopic biopsy in leukemic patients. Gastrointest Endosc 1996;44:620–3. 22. Lloyd GM, Sutton CD, Marshall LJ, et al. Case of duodenal haematoma treated with ultrasound guided drainage. ANZ J Surg 2004;74:500–1. 23. Kwon CI, Ko KH, Kim HY, et al. Bowel obstruction caused by an intramural duodenal hematoma: a case report of endoscopic incision and drainage. J Korean Med Sci 2009;24:179–83.
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