Sarah Olivier-Cabrera, MD, Virendra Tewari, MD, Lakshmi A. Gollapudi, MD, Gustavo Stringel, MD, MBA
Department of Medicine, Division of Gastroenterology and Hepatobiliary Diseases, New York Medical College, Westchester Medical Center, Valhalla, New York (Drs. Olivier-Cabrera, Tewari, Gollapudi).
Department of Surgery, Division of Pediatric Surgery, New York Medical College, Westchester Medical Center, Valhalla, New York (Dr. Stringel).
Introduction: Symptomatic intraperitoneal collections in difficult anatomical locations can present a management chal- lenge. Even after access and drainage are accomplished, reaccumulation of thick material inside the cavity can continue to cause problems. The use of fibrinolytic agents has been reported to facilitate drainage of thick material, hematomas, purulence, and fibrin.
Case Description: We present a 16-year-old male with idiopathic thrombocytopenic purpura who developed a symp- tomatic intraperitoneal hematoma with dimensions of 5 6 6.7 cm, abutting the spleen, pancreas, and left kidney, caused by blunt trauma. Interventional radiology could not drain the cyst because of the location. Initial drainage was done with endoscopic ultrasound (EUS)-guided placement of a lumen apposing self-expandable 1.5 cm wide metal stent designed for cystogastrostomy. The patient continued to be febrile despite saline irrigation used in the initial procedure. Two endoscopic sessions employing thrombolytic agents (4 mg of tissue plasminogen activator and 5 mg of deoxyribonuclease) instillation into the collection at weekly intervals were used. The stent was removed after 8 weeks with complete resolution of the collection. He was discharged home and remained asymptomatic after 1 year of follow-up.
Conclusion: The present case demonstrates the successful and safe use of EUS-guided transgastric drainage in conjunc- tion with fibrinolytic/thrombolytic agents to facilitate dissolution of thickened internal debris, especially in collections with a capsule when mechanical debridement can lead to spillage of infected material and cause generalized peritonitis. To the best of our knowledge, this is the first report of endoscopic drainage utilizing thrombolytic agents.
Key Words: Endoscopic drainage; Intraperitoneal hematoma; Transgastric drainage; Fibrinolytic agents; Thrombolytic agents.