Esophageal hematoma after peroral endoscopic myotomy for achalasia in a patient on antiplatelet therapy.

Peroral endoscopic myotomy (POEM) appears to be a successful technique for the treatment of achalasia [1]. Only a few cases of delayed bleeding have been described [2]. Here, we report a case of esophageal hematoma that developed 1 day after a patient on acetylsalicylic acid (ASA) therapy underwent POEM. A 59-year-old woman with type II achalasia was referred for a POEM procedure. She had a past history of two transient ischemic attacks, which justified continuous therapy with 75mg of ASA per day. Local hemostasis for small areas of muscular hemorrhage was performed with a diathermy forceps. The 16-cm tunnel was closed with five clips. In the following hours, the patient experienced severe epigastric pain, and the next morning, her hemoglobin level had dropped from 144 to 112g/L. She did not have any hematemesis, melena, or hemodynamic instability. A computed tomographic scan showed a large, limited hematoma measuring 34 by 110mm within the tunnel (●" Fig.1), which was closed adequately by the clips. We decided to manage this hematoma conservatively without removing the clips. At day 3, another computed tomographic scan showed a 10-mm decrease in the hematoma. The patient’s condition remained stable, and neither endoscopic hemostasis nor blood transfusion was needed. She was discharged 8 days after the procedure. Her long-term course was favorable, with total resolution of the dysphagia. The risk-to-benefit ratio of POEM depending on various conditions is not known, especially in patients on antiplatelet therapy. Delayed bleeding after POEM is a rare adverse event. To our knowledge, very few cases have been described until now (●" Table1). A conservative treatment can be considered if neither blood exteriorization nor hemodynamic instability is present. Delayed bleeding does not seem to affect the long-term efficacy of the procedure. ASA may increase the risk for bleeding and should be stopped temporarily if possible. If not, the careful preventive coagulation of visible vessels in the tunnel should be performed before it is closed.