2547 Atraumatic Paraduodenal Hematoma in a Patient Presenting With Gastric Outlet Obstruction

Abstract

INTRODUCTION: Paraduodenal hematomas are hematomas occurring alongside, near, and/or around the duodenum, the latter of which is characterized by hemorrhage into the duodenal wall. They have been reported in the setting of abdominal trauma, coagulopathy/anticoagulants, malignancy, chemotherapy, pancreatic disease, alcoholism, and endoscopic procedures. CASE DESCRIPTION/METHODS: A 56-year-old Caucasian male presented with epigastric pain that started 10 days prior to presentation. He described the pain as sharp, up to 10/10 in intensity, non-radiating, waxing and waning, and associated with nausea and multiple episodes of coffee ground emesis. He denied any abdominal trauma and was on no anticoagulation. He drank 2-3 glasses of alcohol every night. On presentation, he was afebrile with normal vital signs. He had a soft abdomen, normal bowel sounds and mild tenderness to palpation in the epigastric region. Laboratory studies were significant for a Hgb of 11.7 g/dL and a WBC count of 13.4 × 109/L. A CT scan of the abdomen with IV contrast revealed an 8 × 8 cm paraduodenal mass. Abdominal magnetic resonance imaging with and without contrast revealed a paraduodenal hematoma approximately 7 × 10 × 8.2 cm in size. The patient was kept NPO and a nasogastric tube was placed. Upper endoscopy revealed intrinsic traversable moderate stenosis at the 2nd part of the duodenum. Repeat abdominal CT scan with and without IV contrast was negative for any aneurysm with no interval change in the paraduodenal hematoma. Total parenteral nutrition was started on the second day of hospitalization and was discontinued on the sixth day. The patient's diet was slowly advanced until he was able to tolerate a full liquid diet. On the day of discharge, the patient did not have abdominal distention, abdominal pain or nausea. The patient was followed two weeks later; he was advanced to a regular diet and had complete resolution of his symptoms. DISCUSSION: Duodenal hematoma was first described by MacLauchan in 1838. Up to 80% of cases are secondary to high impact abdominal trauma. The esophagus, duodenum, jejunum have all been reported to have cases of intramural hematomas. Duodenal hematomas have a higher incidence secondary to the fixed retroperitoneal position; a location that is anterior to the spine makes it highly susceptible to blunt abdominal trauma. Patients can present with abdominal pain, signs of small bowel obstruction, hematemesis, anemia and rarely pancreatitis. Treatment is usually conservative.