Endoscopic Drainage of a Symptomatic Intraperitoneal Hematoma with a Metal Stent and Intracavitary Thrombolytics

Introduction: Symptomatic intraperitoneal collections in difficult anatomical locations can present a management challenge. 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 symptomatic 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 (4mg of tissue plasminogen activator and 5mg of deoxyribonuclease) instillation into the collection at weekly intervals were used. The stent was removed after 8weeks 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 conjunction 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.