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Acute Epigastric Abdominal Pain Post-Gastric Polypectomy
Accepted Manuscript Acute Epigastric Abdominal Pain Post-Gastric Polypectomy Jana G. Hashash, Aline El-Haddad, Kassem Barada
PII: DOI: Reference:
S0016-5085(17)35872-9 10.1053/j.gastro.2017.05.061 YGAST 61274
To appear in: Gastroenterology Accepted Date: 30 May 2017 Please cite this article as: Hashash JG, El-Haddad A, Barada K, Acute Epigastric Abdominal Pain PostGastric Polypectomy, Gastroenterology (2017), doi: 10.1053/j.gastro.2017.05.061. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Acute Epigastric Abdominal Pain Post-Gastric Polypectomy Jana G. Hashash1, 2, Aline El-Haddad1, Kassem Barada1
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1. Division of Gastroenterology, American University of Beirut, and 2. Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh
Aline El-Haddad, MD Fellow, Division of Gastroenterology American University of Beirut email: [email protected] Phone: +961-1-374374; Fax: +961-1-365612
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Kassem Barada, MD Professor of Medicine Division of Gastroenterology American University of Beirut email: [email protected] Phone: +961-1-374374; Fax: +961-1-365612
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Jana G. Hashash, MD, MSc (Corresponding Author) Assistant Professor of Medicine Division of Gastroenterology, Hepatology, and Nutrition - University of Pittsburgh Division of Gastroenterology - American University of Beirut 200 Lothrop Street Mezzanine Level C Wing, Pittsburgh, PA 15213 email: [email protected] Phone: 412-647-7827; Fax: 412-864-1204
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Conflicts of interest: No conflicts of interest exist Sources of funding: None
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Keywords: snare polypectomy; hot snare; abdominal pain; hematoma Author’s Contributions: JG Hashash: Study concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript. A El-Haddad: Acquisition of data; analysis and interpretation of data; drafting of the manuscript. K Barada: Acquisition of data; analysis and interpretation of data; study supervision; critical review of the manuscript.
ACCEPTED MANUSCRIPT
Case: A 56 year-old female presented to our endoscopy suite for an upper endoscopy and colonoscopy to further evaluate iron deficiency anemia. Her home medications included esomeprazole 20 mg po daily for heartburn, pravastatin for dyslipidemia, and propranolol for migraine headaches. During the
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upper endoscopy, the patient was found to have a 2-cm broad based polyp at the incisura (Figure A). The remainder of her upper endoscopy was unremarkable. Hot snare polypectomy was performed and there was no bleeding noted during or at the end of the maneuver (Figure B). Prophylactically, 2
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hemostatic clips were deployed over the polypectomy site to prevent a delayed bleeding complication (Figure C). The patient was discharged home in excellent condition after the procedure. She tolerated a
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regular diet without any problems. Eight hours after the procedure, she experienced a sharp, nonradiating epigastric abdominal pain which was severe in intensity. This pain was associated with one episode of non-bilious, non-bloody vomiting after which she presented to the emergency room for further evaluation. Upon presentation to the emergency room, the patient appeared in moderate
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distress due to the abdominal pain. Her vital signs included a blood pressure of 117/70 mmHg, a pulse rate of 89 bpm, and a temperature of 37.2'C. Abdomen was soft, non-distended, and she had moderate epigastric tenderness. Digital rectal examination revealed brown stools. Blood work was obtained and
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this showed mild leukocytosis (WBC 12,300/cu.mm) with neutrophilic predominance (78%). The patient's hemoglobin was 11.6 g/dL (her baseline hemoglobin was 11.1 g/dL just prior to endoscopy)
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and her platelets were 199,000/cu.mm . To further evaluate the abdominal pain, a contrast enhanced CT scan of the abdomen and pelvis was obtained (Figures D and E). While in the emergency room, the patient's abdominal pain improved without any medical intervention. What is the etiology for the patient's epigastric abdominal pain and how should this patient be managed?
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Answer: The CT scan demonstrated thickening of the gastric antrum and body with a density of 27 HU (arrows on Figures D and E). These findings were consistent with an intramural hematoma (IMH) with no evidence of active bleeding, intraperitoneal free air, or contrast leak. Our patient was
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hemodynamically stable and her pain self resolved while she was in the emergency room. Due to lack of signs and symptoms of intra-luminal bleeding, she was managed conservatively as an outpatient. No repeat upper endoscopy was performed. The patient's daily proton pump inhibitor dosing was
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increased to twice a day and she was started on a clear liquid diet and asked to slowly advance to a regular diet over the following 24-48 hours. She did well and remained pain free. Of note, the
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pathology from the patient's gastric polyp returned as a hamartomatous polyp.
Gastric IMH is a very rare complication of endoscopic mucosal resection (EMR) and all endoscopists should be aware of this potential complication. [1] Risk factors for IMH include trauma, anticoagulation use, hemophilia, amyloidosis, pancreatic diseases, peptic ulcer disease, amongst other causes. [2] IMH
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more commonly occurs in the esophagus and duodenum rather than the gastric wall. It has been thought that the underlying mechanism for IMH is due to vessel damage from submucosal injection rather than from blood leaks due to vessel damage as a consequence of a burn effect. [2] In our patient,
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submucosal injection was not performed and the only intervention was an EMR, so the likely explanation for the complication is due to vessel leakage from burn effect. The preferred test of choice
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to diagnose a gastric IMH is a CT scan. In patients with gastric IMH who are hemodynamically stable and who show no signs or symptoms of intra-luminal bleeding, as in the case of our patient, conservative management is recommended. There have been reports of patients requiring endoscopic hemostatic clip placement, transcatheter arterial embolization, and rarely surgery to control the bleeding. [2, 3]
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References: 1. Dhawan V, Mohamed A, Fedorak RN. Gastric intramucosal hematoma: a case report and literature review. Can J Gastroenterol. 2009;23:19-22.
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2. Park JJ, Jung S, Ju SB, et al. A Case of a Large, GastricIntramural Hematoma Caused by Endoscopic Mucosal Resection, and Treated with Transcatheter Arterial Embolization. The Korean Journal of Medicine. Vol 89, No 3, 2015. p317-322.
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3. Iijima-Dohi N, Shinji A, Shimizu T, et al. Recurrent gastric hemorrhaging with large submucosal hematomas in a patient with primary AL systemic amyloidosis: Endoscopic and histopathologic findings. Intern Med 2004;43:468-72.
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PII: DOI: Reference:
S0016-5085(17)35872-9 10.1053/j.gastro.2017.05.061 YGAST 61274
To appear in: Gastroenterology Accepted Date: 30 May 2017 Please cite this article as: Hashash JG, El-Haddad A, Barada K, Acute Epigastric Abdominal Pain PostGastric Polypectomy, Gastroenterology (2017), doi: 10.1053/j.gastro.2017.05.061. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Acute Epigastric Abdominal Pain Post-Gastric Polypectomy Jana G. Hashash1, 2, Aline El-Haddad1, Kassem Barada1
RI PT
1. Division of Gastroenterology, American University of Beirut, and 2. Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh
Aline El-Haddad, MD Fellow, Division of Gastroenterology American University of Beirut email: [email protected] Phone: +961-1-374374; Fax: +961-1-365612
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Kassem Barada, MD Professor of Medicine Division of Gastroenterology American University of Beirut email: [email protected] Phone: +961-1-374374; Fax: +961-1-365612
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Jana G. Hashash, MD, MSc (Corresponding Author) Assistant Professor of Medicine Division of Gastroenterology, Hepatology, and Nutrition - University of Pittsburgh Division of Gastroenterology - American University of Beirut 200 Lothrop Street Mezzanine Level C Wing, Pittsburgh, PA 15213 email: [email protected] Phone: 412-647-7827; Fax: 412-864-1204
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Conflicts of interest: No conflicts of interest exist Sources of funding: None
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Keywords: snare polypectomy; hot snare; abdominal pain; hematoma Author’s Contributions: JG Hashash: Study concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript. A El-Haddad: Acquisition of data; analysis and interpretation of data; drafting of the manuscript. K Barada: Acquisition of data; analysis and interpretation of data; study supervision; critical review of the manuscript.
ACCEPTED MANUSCRIPT
Case: A 56 year-old female presented to our endoscopy suite for an upper endoscopy and colonoscopy to further evaluate iron deficiency anemia. Her home medications included esomeprazole 20 mg po daily for heartburn, pravastatin for dyslipidemia, and propranolol for migraine headaches. During the
RI PT
upper endoscopy, the patient was found to have a 2-cm broad based polyp at the incisura (Figure A). The remainder of her upper endoscopy was unremarkable. Hot snare polypectomy was performed and there was no bleeding noted during or at the end of the maneuver (Figure B). Prophylactically, 2
SC
hemostatic clips were deployed over the polypectomy site to prevent a delayed bleeding complication (Figure C). The patient was discharged home in excellent condition after the procedure. She tolerated a
M AN U
regular diet without any problems. Eight hours after the procedure, she experienced a sharp, nonradiating epigastric abdominal pain which was severe in intensity. This pain was associated with one episode of non-bilious, non-bloody vomiting after which she presented to the emergency room for further evaluation. Upon presentation to the emergency room, the patient appeared in moderate
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distress due to the abdominal pain. Her vital signs included a blood pressure of 117/70 mmHg, a pulse rate of 89 bpm, and a temperature of 37.2'C. Abdomen was soft, non-distended, and she had moderate epigastric tenderness. Digital rectal examination revealed brown stools. Blood work was obtained and
EP
this showed mild leukocytosis (WBC 12,300/cu.mm) with neutrophilic predominance (78%). The patient's hemoglobin was 11.6 g/dL (her baseline hemoglobin was 11.1 g/dL just prior to endoscopy)
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and her platelets were 199,000/cu.mm . To further evaluate the abdominal pain, a contrast enhanced CT scan of the abdomen and pelvis was obtained (Figures D and E). While in the emergency room, the patient's abdominal pain improved without any medical intervention. What is the etiology for the patient's epigastric abdominal pain and how should this patient be managed?
ACCEPTED MANUSCRIPT
Answer: The CT scan demonstrated thickening of the gastric antrum and body with a density of 27 HU (arrows on Figures D and E). These findings were consistent with an intramural hematoma (IMH) with no evidence of active bleeding, intraperitoneal free air, or contrast leak. Our patient was
RI PT
hemodynamically stable and her pain self resolved while she was in the emergency room. Due to lack of signs and symptoms of intra-luminal bleeding, she was managed conservatively as an outpatient. No repeat upper endoscopy was performed. The patient's daily proton pump inhibitor dosing was
SC
increased to twice a day and she was started on a clear liquid diet and asked to slowly advance to a regular diet over the following 24-48 hours. She did well and remained pain free. Of note, the
M AN U
pathology from the patient's gastric polyp returned as a hamartomatous polyp.
Gastric IMH is a very rare complication of endoscopic mucosal resection (EMR) and all endoscopists should be aware of this potential complication. [1] Risk factors for IMH include trauma, anticoagulation use, hemophilia, amyloidosis, pancreatic diseases, peptic ulcer disease, amongst other causes. [2] IMH
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more commonly occurs in the esophagus and duodenum rather than the gastric wall. It has been thought that the underlying mechanism for IMH is due to vessel damage from submucosal injection rather than from blood leaks due to vessel damage as a consequence of a burn effect. [2] In our patient,
EP
submucosal injection was not performed and the only intervention was an EMR, so the likely explanation for the complication is due to vessel leakage from burn effect. The preferred test of choice
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to diagnose a gastric IMH is a CT scan. In patients with gastric IMH who are hemodynamically stable and who show no signs or symptoms of intra-luminal bleeding, as in the case of our patient, conservative management is recommended. There have been reports of patients requiring endoscopic hemostatic clip placement, transcatheter arterial embolization, and rarely surgery to control the bleeding. [2, 3]
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References: 1. Dhawan V, Mohamed A, Fedorak RN. Gastric intramucosal hematoma: a case report and literature review. Can J Gastroenterol. 2009;23:19-22.
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2. Park JJ, Jung S, Ju SB, et al. A Case of a Large, GastricIntramural Hematoma Caused by Endoscopic Mucosal Resection, and Treated with Transcatheter Arterial Embolization. The Korean Journal of Medicine. Vol 89, No 3, 2015. p317-322.
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3. Iijima-Dohi N, Shinji A, Shimizu T, et al. Recurrent gastric hemorrhaging with large submucosal hematomas in a patient with primary AL systemic amyloidosis: Endoscopic and histopathologic findings. Intern Med 2004;43:468-72.
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