Post written by Theodore W. James, MD, from the Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.
We present the first reported use of an EUS-guided gastrojejunostomy for the treatment of gastric outlet obstruction from a large duodenal hematoma. A 44-year-old man with a history of alcoholic pancreatitis presented with 6 weeks of nausea, vomiting, and inability to tolerate oral intake. He reported a preceding fall while intoxicated and suffered blunt force injury to the abdomen. CT demonstrated a pancreatic pseudocyst and large hematoma compressing the second and third portions of the duodenum with gastric outlet obstruction (GOO). Surgical consultation felt he was not an operative candidate and TPN was initiated. The decision was made to create an EUS-guided gastroenterostomy for relief of GOO. A 0.025-in x 450-cm angled VisiGlide wire was passed into the jejunum, and a 7F orojejunal tube was advanced over the wire. Contrast mixed with saline and methylene blue was infused through the orogastric tube to distend the jejunum for localization via fluoroscopy and EUS. Once an appropriate position in the stomach was identified, the common wall between the stomach and jejunum was interrogated utilizing color Doppler imaging to identify interposing vessels. The stomach wall and the jejunum were punctured under endosonographic guidance using a 15-mm x 10-mm lumen-apposing metal stent (LAMS) and electrocautery device. The stent was advanced into the jejunum and deployed under EUS and endoscopic guidance.
Operative management of a duodenal hematoma consists of surgical evacuation of the hematoma and seromuscular repair when indicated. Non-operative management has historically consisted of post-pyloric feeding tube placement while awaiting resorption of the hematoma, which in some cases may take weeks to months. EUS-guided gastrojejunostomy for the treatment of gastric outlet obstruction from a large duodenal hematoma may be used as an alternative to surgical or radiologic management and allows restoration of enteral access to avoid prolonged post-pyloric feeding.
Training in therapeutic EUS allows the endoscopist to look at problems differently. By understanding the potential treatment options, such as EUS-GJ in this case, one can offer the patient a better treatment modality.
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