Endoscopic perception of a large duodenal hematoma, the advantage of two channels. Primary author Philip Kozen. Co-authors Anna H. Lee, Anna Skay, Zephyr Humidi, V. Raman Muthusamy, Danny Issa. Our disclosures are listed below. A 60-year-old female with no past medical history presented with melanoma. Initial endoscopy showed a large polyp with a broad stalk in the duodenum with an ulcerated tip. Despite initial treatment with argon plasma coagulation and endoclips, melanoma persisted requiring a repeat endoscopy and resection of the polyp. We describe a resection of the polyp through a prophylactic end-loop applicator of the stalk, followed by a novel technique of simultaneous resection and pull-away using a double-channel endoscope. The polyp was located in the posterior wall of the distal bulb and had a broad stalk and prolapsed into the second portion of the duodenum. The polyp measured approximately 4 centimeters in length and the stalk measured more than 1 centimeter in diameter. Stigmata of recent bleeding was seen on the tip of the polyp. An endoscopic ultrasound was first performed and showed a hyperechoic homogeneous mass originating from the mucosal layer. No vascular structures were seen. First, two endoclips have been placed at the base of the stalk as bleeding prophylaxis. An end-loop applicator was deployed at the base of the stalk to allow for safe resection. Once we confirmed a good control of the stalk, a 33-millimeter SIF snare was advanced through the smaller channel of the endoscope and positioned at the stalk above the end-loop. Simultaneously, a retrieval net was advanced through the second channel and was used to grab the body of the polyp. This maneuver allowed for excellent control of the lesion. The stock was resected using a blended current while the body of the pulp was captured and pushed distally using the retrieval net. Resection of the pulp was completed. The polyp was retrieved with a slow, steady pull to pass the pyloric sphincter and then the upper esophageal sphincter while applying jaw thrust. Here are our endoscopic methods summarized, and followed by a short video detailing our technique. The endoscope was reintroduced and the site reexamined. No bleeding or perforation was noted. Two additional endoclips were placed at the resection site to prevent bleeding. Close inspection was performed at the pylorus and the soft gill sphincters, and again, no injury was noted. Lastly, we have pathology shown here, first with the growth specimen showing a four centimeter long mass with a visible ulcer, and followed by an H&E showing duodenal mucosa with underlying hyperplastic Brunner's glands at times 20 magnification and times 100 magnification showing proliferated Brunner's glands arranged in lobules with no dysplasia. This case highlights that large duodenal hematomas, although rare, can at times present a significant GI bleeding, necessitating urgent removal. Despite the large size, these polyps can be amenable for endoscopic resection and retrieval. The use of a two-channel endoscope allowed for simultaneous cut and capture to minimize the risk of specimen loss while providing a minimally invasive approach for resection. Duodenal hematomas are an uncommon cause of gastrointestinal bleeding. Endoscopic resection can be performed safely in a minimally invasive way using a technique of pulling away while cutting the base of the lesion through a double-channel endoscope with excellent outcomes.

case study

melanoma

duodenum

polyp

double-channel endoscope