EUS–guided aspirate of a traumatic paraduodenal duodenal hematoma with gastric outlet obstruction (with videos)

A 16-year-old male presented to our institution with right upper quadrant pain, nausea and vomiting. This was on a background of sustaining blunt force abdominal trauma to the epigastrium 1 day prior. Initial examination revealed right upper quadrant tenderness. Biochemical assessment revealed a hemoglobin of 145 g/L. His coagulation profile was normal. Abdominal ultrasound revealed a large collection suggestive of a hematoma in right upper quadrant measuring 58 mm × 95 mm × 43 mm [Figure 1A]. Computed tomography (CT) abdomen demonstrated a heterogeneous collection in a paraduodenal location suggestive of a paraduodenal hematoma [Figure 1B and C]. Due to clinical concern for intestinal obstruction, a nasogastric tube was inserted for gastric decompression.Figure 1: A, Abdominal ultrasound demonstrating large intra-abdominal collection in the right upper quadrant; B, Computed tomography (CT) abdomen with axial view demonstrating paraduodenal hematoma; C, CT abdomen with coronal view demonstrating paraduodenal hematoma with subsequent mass effects resulting in gastric outlet obstruction.EUS was performed; however, the echoendoscope was not able to advance into the duodenal bulb due to abnormal configuration of the stomach secondary to mass effects from the paraduodenal hematoma. A large heterogenous collection adjacent to the gallbladder was identified from the antrum of the stomach measuring 70 mm × 40 mm [Figure 2; Video 1].Figure 2: EUS demonstrating large heterogenous collection adjacent to the gallbladder. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Initial EUS demonstrating large heterogenous collection (70 mm x 40 mm) suggestive of a paraduodenal haematoma, visualised from the antrum of the stomach adjacent to the gallbladder.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_dug361v3"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The collection was targeted under color Doppler guidance with a 19G Expect needle [Figure 3A; Video 2]. Blood (125 mL) was aspirated from the collection resulting in symptomatic alleviation [Figure 3B; Video 3]. The echoendoscope was then exchanged for a gastroscope. Extrinsic compression was identified in the first portion of the duodenum; however, this could be easily traversed with the gastroscope (Video 4). Post-procedure, the patient's symptoms of gastric outlet obstruction had resolved, and the patient was discharged to home.Figure 3: A, EUS imaging demonstrating puncture the paraduodenal hematoma; B, EUS imaging demonstrating aspiration and collapse of the paraduodenal hematoma. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"EUS guided paraduodenal haematoma aspiration under color doppler guidance using a 19G Expect needle.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_efrwhwzo"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3","caption":"Decompression of paraduodenal haematoma post aspiration under EUS guidance.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_k4sa4cfv"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4","caption":"Re-look gastroscopy identifying extrinsic compression in the first portion of the duodenum easily traversed with an adult gastroscope demonstrating alleviation of gastric outlet obstruction.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_rlyqdhhb"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Intestinal hematomas are relatively uncommon, with the 2 main types being intramural and paraduodenal.[1] The most common cause of a paraduodenal hematoma is trauma, with less common etiologies including coagulopathies, endoscopy related, pancreatitis, and anticoagulant use.[2] Symptoms associated with a paraduodenal hematoma include abdominal pain and vomiting; however, mass effects associated with the hematoma can result in intestinal, biliary, or pancreatic ductal obstruction; intraluminal hemorrhage; perforation; or ischemia, with disastrous consequences. The management in those without significant adverse effects is largely conservative; however, in those who develop complications, surgical intervention is warranted.[3]Endoscopic management of intestinal hematomas is an attractive option and has emerged as a minimally invasive method through which decompression can be achieved. Previous reports have detailed the role of endoscopy and EUS in the management of luminal obstruction secondary to intramural duodenal hematomas; however, the role of endoscopic drainage in paraduodenal hematomas is yet to be established.[4,5] In conclusion, EUS-guided decompression of paraduodenal hematomas is an attractive minimally invasive treatment option and should be considered in those who develop significant adverse effects associated with obstruction.