JPGN Reports · 3 authors, 2 centres
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A 12-year-old boy developed a rare dissecting duodenal hematoma after routine EGD with biopsies for suspected celiac disease, causing obstruction and pancreatitis. The hematoma required surgical evacuation, and the patient recovered after 2 weeks. This case highlights the need to weigh risks of endoscopic confirmation against serologic diagnosis in celiac disease.
**Background:** Duodenal hematoma is a rare but serious complication of esophagogastroduodenoscopy (EGD) with biopsies, particularly in pediatric patients. Post-EGD bleeding rates are low (0.11–0.3% in pediatrics), and duodenal hematomas occur in only 0.05% of EGDs with biopsies. This case describes a dissecting duodenal hematoma, a more severe variant, in a child undergoing routine EGD for suspected celiac disease.
**Methods:** This is a case report of a 12-year-old boy who presented to the emergency department with abdominal pain, distention, and nonbloody, nonbilious emesis one day after routine EGD with biopsies for suspected celiac disease. The suspicion was based on gastrointestinal symptoms and elevated tissue transglutaminase IgA. Physical exam revealed epigastric tenderness, abdominal distention, and tachycardia. He was not malnourished (BMI 17.4, Z-score −0.43). Labs showed a lipase concentration of 10,261 U/L (upper limit of normal 195 U/L). CT of the abdomen and pelvis with oral and intravenous contrast revealed a dilated stomach and proximal duodenum, hemoperitoneum, and a dissecting intramural hematoma involving the second and third portions of the duodenum causing obstruction and pancreatitis. The patient was transferred to a tertiary care center ICU. Given the extent of the hematoma, evolving abdominal exam, hemodynamic instability, and concern for possible perforation, he underwent urgent exploratory laparoscopy and retroperitoneal duodenal hematoma evacuation within 24 hours of transfer. No perforation was found. Coagulopathy workup was negative.
**Key Results:** The hematoma improved on subsequent fluoroscopic imaging. The patient recovered with bowel rest and decompression. He was discharged 2 weeks later after slow nutritional advancement to a liquid diet. Within a month of diagnosis, he was tolerating a full gluten-free diet with no residual symptoms. The case highlights that while most duodenal hematomas (14/14 in a pediatric case series) are managed conservatively, this case was complicated by duodenal dissection requiring surgical intervention. Coagulopathy and organ transplant recipient status are possible risk factors, but the patient had a normal INR. Celiac disease has been hypothesized as a risk factor for endoscopic complications, but this is not confirmed.
**Clinical Implications:** This case underscores the rarity of dissecting duodenal hematoma after routine EGD with biopsies and the potential need for surgical intervention. It emphasizes the importance of balancing the risks and benefits of endoscopic confirmation of celiac disease, especially when serologic diagnosis (ESPGHAN criteria) is available. Clinicians should be aware of this complication and consider it in patients presenting with abdominal pain, distention, and elevated lipase after EGD.