St. George's University School of Medicine New York, NY, United States
Panayotis Jusakos, BS1, Donevan Westerveld, MD2, David Wan, MD3 1St. George's University School of Medicine, New York, NY; 2New York-Presbyterian-Weill Cornell Medical Center, New York, NY; 3New York-Presbyterian/Weill Cornell Medical Center, New York, NY
Introduction: Gastrointestinal bleeding (GIB) is a common cause of hospitalizations. Small bowel GI (SBGI) bleeds account for 5-10% of all patients presenting with GIB. Due to inability to visualize the bowel properly, common complications of SBGI include multiple blood transfusions, recurrent hospitalizations, and multiple diagnostic investigations; all taxing on the patient and contribute to rising healthcare cost. Intermural Hematoma is a rare complication of SBGI with overall incidence of 1/2500.
Case Description/Methods: We report the case of a 73-year-old male, medical history of atrial fibrillation on Apixiban who presented to ED with fatigue and dark bloody stools for 5 days. Vital signs were unremarkable. A digital rectal exam revealed maroon colored stool. Laboratory values were notable for Hgb 4.5 g/dL, INR 1.2, and BUN/Cr 20. Packed RBC’s were transfused and high dose PPI administered.
Esophagogastroduodenoscopy revealed multiple Forrest class III duodenal ulcers. Colonoscopy showed bright red blood throughout examined colon. Due to persistent bleeding CT angiography performed but was inconclusive. A video capsule endoscopy (VCE) revealed a jejunal lesion not actively bleeding (1). Subsequently, technetium-labeled RBC scan showed radiotracer activity within a loop of jejunum likely correlating to VCE finding. Interventional radiology consulted and embolization of jejunal loop of superior mesenteric artery was performed. Patients bleeding initially improved but recurrence of melanic stool required blood transfusion 3 days post embolization. CT enterography performed noting barely perceptible 3 mm focus of jejunal enhancement. Double balloon enteroscopy was preformed, notable for submucosal jejunal mass with central ulceration. Lesion ligated with endoloop and removed with snare cautery. Patients bleeding stopped, and he was safely discharged. Biopsy results of mass was consistent with a hematoma.
Discussion: Management of SBGI often requires multiple modalities and interventions. Development of spontaneous intestinal intramural hematoma is a rare cause of SBGI. A common risk factor is anticoagulation use and a common location is the jejunum. If not addressed urgently, these hematomas can progress and cause small bowel obstruction. Treatment typically consists of medical management and surgical resection if obstruction is present. In this case we successfully treated and resected the intramural hematoma using an endoloop and snare cautery device.
Figure: Figure 1. Video Capsule Endoscopy with apparent mass in the jejunum
Disclosures: Panayotis Jusakos indicated no relevant financial relationships. Donevan Westerveld indicated no relevant financial relationships. David Wan indicated no relevant financial relationships.
Panayotis Jusakos, BS1, Donevan Westerveld, MD2, David Wan, MD3. P0488 - A What? The Small Bowel Hematoma Presenting as a Jejunal Lesion, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.