Delayed bleeding and intratunnel hematoma after peroral endoscopic myotomy: salvage endoscopy management with full recovery

Peroral endoscopy myotomy (POEM) is a safe technique for achalasia management [1]. The rate of major complications is commonly < 5 % in the largest series [2] [3] [4]; delayed bleeding with intratunnel hematoma (< 0.5 %) is infrequently reported. Hematoma and local compression effects can induce ischemic phenomena with ulceration, as well as hemodynamic effects triggered by active bleeding. Symptoms begin within 24–48 hours, generally with hematemesis and progressive retrosternal pain after several hours of active bleeding. If suspected, urgent chest computed tomography (CT) can confirm the diagnosis [5]. This complication is not exclusively associated with anticoagulation therapy, thus, we need to be alert.

Once confirmed, emergency endoscopy within 24–48 hours for mechanical removal of the intratunnel clot and local hemostasia is recommended. Typical findings include large clots covering the submucosa tunnel and blue color of the upper mucosa. Mucosotomy clips should be removed in order to enter the tunnel. Careful work is required to remove all clots ([Fig. 1]) and expose active bleeding vessels with hemostatic forceps. Foreign-body forceps and polypectomy snare could be used to fragment and remove the clots. In cases of failure, a Sengstaken–Blakemore tube or covered stent could be placed; several reports have described their use regardless of the success of endoscopic removal of the intratunnel clots.

Fig. 1 Interior of the tunnel after clot removal and coagulation of bleeding vessels.

We present the case of a 76-year-old man who complained of hematemesis and retrosternal pain 16 hours after uneventful POEM for achalasia type II. CT chest showed a large hematoma 10 cm in length in the middle and lower esophagus with no signs of active bleeding. Salvage gastroscopy was performed following the steps described previously ([Fig. 2], [Video 1]).

Fig. 2 Blue color of the esophageal mucosa immediately after salvage endoscopy.

Video 1 Hematoma after peroral endoscopic myotomy: step-by-step resolution of a complication.

After 1 week, the hematoma did not re-emerge, but ischemic phenomena appeared in the distal esophagus ([Fig. 3]). Clips were placed to approximate the edges of the ulcer to aid mucosal healing. After 3 weeks on proton pump inhibitors and nil per os, endoscopy showed complete scarring of the mucosotomy and distal esophageal ulcer ([Fig. 4], [Fig. 5]), and the patient could resume a diet and was discharged. At 2 months after discharge, the patient had no symptoms with a normal diet.

Fig. 3 An ulcer in the distal esophagus, secondary to ischemic phenomena.

Fig. 4 The middle esophagus 3 weeks after peroral endoscopic myotomy.

Fig. 5 Complete healing of the distal ulcer esophagus 2 weeks after its identification.

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Publication History

Article published online:
18 June 2021

• References

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