S2774 An Unusual Case of Duodenal Obstruction from an Unsuspected Intramural Hematoma

Abstract

INTRODUCTION: Intramural duodenal hematoma (IDH) is an unusual presentation after blunt abdominal trauma. IDH rarely leads to gastric outlet obstruction (GOO), acute pancreatitis, obstructive cholestasis, and gastrointestinal hemorrhage. We report first case of delayed presentation of large IDH associated with acute pancreatitis and GOO four months after abdominal trauma. CASE DESCRIPTION/METHODS: A 53-year-old man with history of diabetes mellitus, alcohol use disorder presented with upper abdominal pain, nausea and vomiting of 2 days duration. Reports fall on to the edge of bathtub and hitting his abdomen 4 months ago. Abdominal exam revealed a non-tender palpable mass in the epigastrium. Labs were significant for elevated AST-214, ALT-63, ALP- 218, lipase-419, and CA 19-9 -377.8. A CT scan of Abdomen showed a large duodenal intramural mass without enhancement and upstream GOO, which is new compared to prior CT scan done a year ago for other reasons. An MRI of the abdomen showed a large heterogeneous duodenal filling defect, with no internal enhancement likely representing a hematoma (Figure 1). Patient underwent EGD and Endoscopic ultrasound(EUS) that showed a submucosal duodenal mass occupying the entire lumen of the duodenum (Figure 2). FNA showed many inflammatory and necrotic cells and was non-diagnostic. Patient had persistent obstruction despite one week of conservative therapy with Nasogastric decompression and TPN (Figure 3). He underwent surgical hematoma evacuation with a feeding jejunostomy tube placement and was discharged on post-operative day 7 after tolerating oral feeds, normalization of lipase and LFTs. DISCUSSION: Most cases of IDH are secondary to blunt abdominal trauma. Spontaneous IDH occurs in patients with bleeding disorders, anticoagulation therapy, vascular collagen diseases, or after invasive endoscopic procedures. IDH is more frequent among children. Due to its anatomic location and high submucosal vascularity distal duodenum is the most common site involved. Symptomatic patients present with GOO symptoms. Compression of the ampulla or pancreatobiliary ducts can cause acute pancreatitis and obstructive jaundice. Cross sectional imaging aids in diagnosis and to evaluate for complications such as perforation or retroperitoneal hemorrhage. EGD and EUS are helpful when imaging is inconclusive. Most patients improve with conservative management by 1 week. Surgical, image guided or endoscopic drainage is needed in patients who fail conservative management or develop complications.Figure 1.: A: CT scan of abdomen showing large heterogeneous filling defect ( arrow) extending from 1st to 3rd portion of duodenum, measuring at least 13 cm × 5.6 cm resulting in upstream gastric outlet obstruction, as evidenced by distended stomach and contrast not passing in to small bowel. B: MRI of abdomen- Post contrast subtraction films showing large heterogenous filling defect (arrow) with no internal enhancement, likely representing a hematoma.Figure 2.: A: ESD showing large 4-5 cm smooth, subepithelial duodenal mass involving the bulb and the duodenal sweep occupying 99% of the lumen of the duodenum. B: -Linear EUS imaging showing a 37.2 mm × 60.5 mm subepithelial lesion in the duodenal bulb. Due to local inflammation and the large size of the lesion, the layers of the duodenum could not be well defined.Figure 3.: Upper Gastrointestinal series showing filling defect in the lateral aspect of the duodenum with a narrow trail of contrast coursing in the residual medial lumen at 1 week of conservative therapy.