Post written by Bakht S. Cheema, MD, from Digestive Disease Consultants, and Yusuke Hashimoto, MD, MMA, from the University of Florida Health, Jacksonville, Florida, USA.

A 44-year-old man presented with postprandial vomiting and jaundice. He had an episode of acute-on-chronic pancreatitis complicated with a pseudocyst and a spontaneous large duodenal intramural hemorrhage causing duodenal luminal obstruction and functional biliary obstruction by compressing the major papilla.

We illustrate endoscopic needle-knife incision and drainage of the duodenal intramural hematoma relieving duodenal and biliary obstruction and facilitating subsequent interventions.

Duodenal intramural hematomas causing obstruction of the duodenal lumen and the biliary system are a rare occurrence. Most of these hematomas are managed conservatively. This patient had symptoms of obstruction. Hence, interventions were planned.

EUS showed the hematoma cavity enclosed within layer 4 of the duodenum, ensuring there was no perforation or communication. Therefore, drainage by using a needle-knife was carefully performed.

Needle-knife incision and drainage have been used in limited settings to drain intramural hematomas or fluid collections. With high-quality cross-sectional and endosonographic images, the risks for perforation and adverse events can be minimized.

Successful use of this technique would necessitate proficiency in needle-knife sphincterotomies during ERCP. Our experience can help expand the armamentarium available to advanced endoscopists if faced with challenging situations.

Needle-knife incision and drainage of the hematoma.

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