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phoma had been treated with autologous peripheral blood stem cell transplanta− tion. He had evident hematological defi− cits, with thrombocytopenia (56 000  109/L), but with normal coagulation. Due to persistent epigastralgia, panendoscopy was conducted in order to take a gastric biopsy and a duodenal biopsy to exclude graft−versus−host disease after the plate− let transfusion. One day later, the boy suffered abdominal pain, fullness, and vomiting. Physical examination dem− onstrated diffuse tenderness over the upper abdominal quadrant. The hemato− crit dropped from 30.8 % to 22.6%. Ab− dominal computed tomography without (l" Fig. 1 a) and with contrast (l" Fig. 1 b) disclosed a diffuse intramural hematoma of the duodenum, extending from the first portion to the fourth portion. This diffuse duodenal intramural hematoma resulted in severe necrotizing pancreati− tis with acute respiratory distress syn− drome and septic shock. The patient died 2 weeks later. Duodenal intramural hematoma is a rare condition, and can sporadically be seen in patients with trauma, hematological deficits, or pancreatic cancer, or in those using anticoagulants [1± 4]. Iatrogenic trauma caused by either endoscopic duo− denal biopsy or therapeutic injection to a bleeding ulcer can also lead to duodenal intramural hematoma, but is usually self−limited without lethal outcome [4, 5]. However, in our patient the duode− nal biopsy induced a lethal hematoma: it was diffusely extended from the first to the fourth portion and thus obliterated the pancreatic drainage, leading to severe necrotizing pancreatitis. Evacuation of the hematoma by surgery was limited by the hematological deficits in this case. Despite the correction of the platelet counts and normal coagulation param− eters, this case shows that the risk of mor− tality from duodenal biopsy still exists. Caution dictates that duodenal biopsy should be avoided during panendoscopy in patients in whom the possibility of sur− gery is limited by hematological deficits.

Diffuse intramural duodenal hematoma complicated by lethal necrotizing pancreatitis after endoscopic duodenal biopsy