Clin Endosc.  2014 May;47(3):270-274. 10.5946/ce.2014.47.3.270.

Acute Duodenal Ischemia and Periampullary Intramural Hematoma after an Uneventful Endoscopic Retrograde Cholangiopancreatography in a Patient with Primary Myelofibrosis

• Jung CH
• Hyun JJ
• Gu DH
• Moon ES
• Kim JS
• Lee HS
• Kim CD

• KMID: 2049026
• DOI: http://doi.org/10.5946/ce.2014.47.3.270

Abstract

Acute duodenal ischemia and periampullary intramural hematoma are rare complications after endoscopic retrograde cholangiopancreatography (ERCP). A 77-year-old man with splenomegaly complained of abdominal pain caused by common bile duct (CBD) stone. After successful removal of the CBD stone without immediate complications, the patient developed intramural hematoma around the ampulla of Vater along with diffuse duodenal edema. The findings were compatible with acute intestinal ischemia, and further evaluation revealed that he had underlying primary myelofibrosis. Myeloproliferative diseases are known to be significantly associated with an increased risk of thrombohemorrhagic complications. Therefore, particular attention should be given to this group of patients when a high-risk procedure such as ERCP is performed.

Keyword

Acute duodenal ischemia; Duodenal edema; Cholangiopancreatography, endoscopic retrograde; Periampullary intramural hematoma; Primary myelofibrosis

MeSH Terms

Abdominal Pain
Aged
Ampulla of Vater
Cholangiopancreatography, Endoscopic Retrograde*
Common Bile Duct
Edema
Hematoma*
Humans
Ischemia*
Primary Myelofibrosis*
Splenomegaly

Figure

• 

  Fig. 1 (A) No bleeding occurred after endoscopic sphincterotomy. (B) A black pigment stone is successfully removed using a basket and (C) immediate complications are not observed after the procedure.

• 

  Fig. 2 (A) Initial abdomen computed tomography (CT) reveals a large duodenal diverticulum (arrowheads) on the lateral wall of duodenum second portion. (B) Abdominal CT performed the next day after endoscopic retrograde pancreaticoduodenography (ERCP) shows severe edematous wall thickening of the duodenum (white arrows). Localized focal low-attenuated lesion suggesting hematoma is also observed at the periampullary area (black arrows). (C) Follow-up abdominal CT performed 11 days after ERCP demonstrates considerably improved edematous wall thickening of the duodenum and resolved focal low-attenuated lesion at the periampullary area.

• 

  Fig. 3 (A) Endoscopic examination performed the day after endoscopic retrograde cholangiopancreatography (ERCP) demonstrates diffusely edematous duodenal mucosa with linear ulcerations and a large bulging lesion suggestive of hematoma (black arrows) distal to the ampulla of Vater (arrowhead). (B) Follow-up endoscopy performed 8 days after ERCP shows much improved duodenal wall edema with a large ulcer where the hematoma had been (white arrow).

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