P2777 - A Rare Manifestation of IgG4-Related Disease: Gastric Outlet Obstruction Due to Duodenal Hematoma and Duodenitis

Genanew Bedanie, MD¹, Nirali Sheth, DO², Anastasia Novikov, MD³, Vennis Lourdusamy, MD⁴, Maliyat M. Matin, MD⁵, Richard Mitchell, MD⁶, Aron Joshua, MD⁶, Aaron Walfish, MD⁴, Raghav Bansal, MD⁷, Krishna Gurram, MD⁸, Joel Baum, MD^6
1Icahn School of Medicine at Mount Sinai, New York, NY; ²Icahn School of Medicine Mount Sinai - Elmhurst Hospital Center, Rego Park, NY; ³Elmhurst Hospital Center/ Icahn School of Medicine at Mount Sinai, Elmhurst, NY; ⁴Elmhurst Hospital Center/ Icahn School of Medicine, Elmhurst, NY; ⁵Icahn School of Medicine Mount Sinai - Elmhurst Hospital Center, Elmhurst, NY; ⁶Icahn School of Medicine at Mount Sinai - Elmhurst Hospital, Queens, NY; ⁷Elmhurst Hospital Center, Elmhurst, NY; ⁸Icahn School of Medicine at Mount Sinai, NYC Health + Hospitals/Elmhurst, Queens, NY

Introduction: IgG4 related duodenitis and duodenal hematoma causing gastric outlet obstruction is very rare. It is an immune mediated condition that can affect multiple organs, commonly involving pancreas and salivary glands. Rarely, it can have atypical presentation localized to one or more organs. Our patient presented with symptoms of gastric outlet obstruction (GOO) with duodenal hematoma and required extensive work up and procedures.

Case Description/Methods: A 42-year-old male with dyslipidemia and alcohol use disorder presented with acute onset of epigastric abdominal pain and frequent vomiting. Patient drinks 5 beers daily, denies trauma, bleeding disorders or use of blood thinners. Examination revealed distended and tender epigastric area. Normal coagulation profile and liver enzymes. Elevated Lipase (3893) and Triglycerides (516). Computed tomography (CT) showed a 7x6x6 cm homogenous dense hematoma in the 3^rd portion of duodenum causing GOO, and possible secondary pancreatitis from duodenal hematoma (Figure 1). CT angiogram confirmed duodenal hematoma with no active bleeding. Esophagogastroduodenoscopy (EGD) showed inflamed mucosa and stenosis in the second portion of duodenum. He was Kept nothing per oral with intermittent suction through nasogastric tube. A week later, repeat CT showed persistent GOO, and patient underwent endoscopic ultrasound guided gastrojejunostomy and stenting to bypass the obstruction. At 4 months, repeat CT showed persistent duodenal thickening with resolution of hematoma and EGD revealed edematous and inflamed duodenum with GOO (Figure 2). Due to persistent duodenitis, IgG4 related disease was considered. His IgG4 level was high and biopsy showed plasma cell infiltration. Patient was treated with Prednisone, symptom improved significantly and tolerated regular food even after removal of the stent.

Discussion: IgG4 related duodenitis and duodenal hematoma causing GOO is very rare. High degree of suspicion helps for the diagnosis. Our patient presentation was complicated. GOO and duodenal hematoma were the main problem, and pancreatitis was considered secondary to hematoma extension or related to alcohol or hypertriglyceridemia. A few months later, resolution of hematoma but persistent inflamed duodenum made us to think of IgG4 related multi organ inflammatory syndrome. The diagnosis is made by high serum IgG4 and biopsy showing lymphoplasmacytic infiltration with IgG4 + plasma cells. Treatment with Steroid helps in resolution of disease and some patient may need rituximab.



Disclosures:


Genanew Bedanie, MD¹, Nirali Sheth, DO², Anastasia Novikov, MD³, Vennis Lourdusamy, MD⁴, Maliyat M. Matin, MD⁵, Richard Mitchell, MD⁶, Aron Joshua, MD⁶, Aaron Walfish, MD⁴, Raghav Bansal, MD⁷, Krishna Gurram, MD⁸, Joel Baum, MD⁶. P2777 - A Rare Manifestation of IgG4-Related Disease: Gastric Outlet Obstruction Due to Duodenal Hematoma and Duodenitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.