Description

Intramural duodenal haematoma (IDH) is an uncommon occurrence following endoscopic intervention, specifically endoscopic retrograde cholangiopancreatography (ERCP), and is typically attributed to blunt trauma caused by the endoscope.1 2 IDH generally resolves spontaneously with supportive care. Nevertheless, occasionally, it requires endoscopic, percutaneous or surgical drainage for effective management.3–5

A man in his 40s with an unremarkable medical history, except for cholelithiasis, underwent an ERCP due to acute cholangitis and choledocholithiasis. He had no history of coagulopathy and was not taking anticoagulant or antiplatelet medications. During the procedure, sphincterotomy and extraction of gallstones from the common bile duct were performed. However, biliary cannulation posed a challenge due to an impacted stone above the ampulla of Vater, requiring more than five contacts with the papilla and more than 10 min for successful cannulation. As a result, the procedure was time consuming with inadvertent pancreatic injection, leading to the placement of a prophylactic pancreatic stent. Following ERCP, the patient experienced mild abdominal pain, bilious vomiting and melaena. Physical examination revealed mild tenderness in the upper abdomen but was otherwise unremarkable. The patient was subfebrile and remained haemodynamically stable with a normal heart rate. Urine output was within normal limits. Blood tests showed a 40 g/L decrease in haemoglobin, along with a moderate rise in pancreatic enzyme levels. An urgent duodenoscopy detected a huge bulging mass in the second segment of the duodenum, located on the opposite side of the papilla, congestive and swelling, conditioning luminal obstruction, suggestive of haematoma (figure 1A). An abdominal angio-CT scan confirmed the presence of a massive duodenal wall haematoma, measuring at least 10 cm, without signs of active bleeding (figure 1B). The patient was managed conservatively with close clinical assessment. Four days later, an upper endoscopy was performed to extract the pancreatic stent and showed a less haemorrhagic bulge, although the duodenum was still severely swollen (figure 1C). The patient presented a favourable global evolution and was discharged 12 days later. An abdominal CT scan 4 weeks later revealed complete resorption of haematoma (figure 1D). Posteriorly a laparoscopic cholecystectomy was performed, without incidents.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

(A) Duodenoscopy revealing a large intramural haematoma contralateral to the papilla, almost occluding the duodenum. (B) CT showed findings consistent with an intramural duodenal wall haematoma (D: duodenum; H: haematoma; P: pancreatic stent). (C) Follow-up upper endoscopy showing a less haemorrhagic bulge. (D) Re-evaluation of CT confirming complete resorption of the duodenal haematoma (D: duodenum; Pa: pancreas).

This case report illustrates an unexpected and massive complication after ERCP that was managed successfully with a conservative approach. Thus, invasive procedures, with significant morbidity and mortality, were avoided.