Case Of Intramural Duodenal Hematoma Research Articles

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

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.

S2377 A Triad of Post-ERCP Gastric Outlet Obstruction, Obstructive Jaundice, and Pancreatitis, Is It Intramural Duodenal Hematoma? A Case Report and Review of Literature

INTRODUCTION: Intramural duodenal hematoma (IDH) commonly results after blunt abdominal trauma and occurs very rarely as a complication of endoscopic retrograde cholangiopancreatography (ERCP). The incidence rate of gastrointestinal bleeding-related complications after ERCP is 1.34%. We present here a case of IDH causing gastric outlet obstruction, obstructive jaundice and pancreatitis, managed conservatively. CASE DESCRIPTION/METHODS: An 86-year-old man with ERCP a week ago, involving sphincterotomy for choledocholithiasis presented with epigastric pain associated with nausea and vomiting. Evaluation revealed WBC 17.1 K/UL, lipase 5170 U/L, alanine aminotransferase (ALT) 39 U/L, aspartate aminotransferase (AST) 143 U/L, alkaline phosphatase 170 U/L, total bilirubin 1.7 mg/dL. Common bile duct measured 11mm on abdominal ultrasound, while computed tomography (CT) abdomen with IV contrast revealed distention of the esophagus, stomach, and duodenum with hyperdense shadow in the third and fourth portion of the duodenum starting from the level of the ampulla consistent with intraluminal duodenal hematoma (Figure 1,2). Foci of extraluminal retroperitoneal air and stranding adjacent to the duodenum and inferior vena cava were also noted to be suspicious for perforation of the duodenum. He was diagnosed with duodenal hematoma causing perforation, gastric outlet obstruction, obstructive jaundice and pancreatitis (Figure 3). A nasogastric tube was placed, total parenteral nutrition was initiated for bowel rest, piperacillin-tazobactam due to perforation, and IV fluids and opioids for pancreatitis. Two days later, repeat CT showed decompressed duodenum and with decreasing extraluminal air around duodenum. His symptoms continued to improve, diet was advanced as tolerated during hospitalization, and he was discharged with regular outpatient follow up. DISCUSSION: Stationary duodenum gets compressed against duodenoscope and abdominal wall resulting in hematoma formation. Diagnosis of hematoma is usually made with CT. Initial management consists of supportive measures while surgery is recommended if the condition does not improve with nutritional support and non-operative measures in 10–14 days. The low incidence and nonspecific nature of symptomatology can lead to delay in diagnosis. Gastric outlet obstruction, obstructive jaundice and pancreatitis after ERCP suggest duodenal hematoma. Clinicians should remain alert to the potential symptoms and should screen patients at follow-up visits.Figure 1.: Arrow pointing towards intramural duodenal hematoma.Figure 2.: Arrow pointing towards intramural duodenal hematoma resulting in stomach distention.Figure 3.: Arrow pointing toward inflamed pancreas.

Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review

We present a case of intramural duodenal hematoma as a complication of endoscopic therapy for a bleeding duodenal ulcer in an adult patient with no evidence of other pathologies. A 18-year-old man was admitted in emergency room with gastrointestinal bleeding manifested by melena. Previous medical history revealed that he had endoscopic sclerotherapy for bleeding duodenal ulcer 5 months before. Endoscopy revealed a Forrest 2a ulcer in the duodenal bulb and sclerotherapy was performed by injecting 10 ml of 0.2% epinephrine and 20 ml of Na- Cl 0.9% solution. Upper occlusion's signs appeared 36 hours after the procedure. The hematoma, that was identified by endoscopy and confirmed by MRI and CT scan of the abdomen, caused transient duodenal obstruction. Combined conservative management with nasogastric tube and total parenteral nutrition resulted in reduction of obstructive symptoms within 4 weeks.

A Lethal Complication of Endoscopic Therapy: Duodenal Intramural Hematoma.

Duodenal intramural hematoma (DIH) usually occurs in childhood and young adults following blunt abdominal trauma. It may also develop in the presence of coagulation disorders and may rarely be an iatrogenic outcome of endoscopic procedures. Management of DIH is usually a conservative approach. A case of intramural duodenal hematoma that developed following endoscopic epinephrine sclerotherapy and/or argon plasma coagulation and that was nonresponsive to conservative therapy in a patient with chronic renal failure who died from sepsis is being discussed in this report. Clinicians should be aware of such possible complications after endoscopic hemostasis in patients with coagulation disorders.

A Case of Duodenal Intramural Hematoma Caused by Acute Alcoholic Pancreatitis

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A Rare Cause of Acute Pancreatitis: Intramural Duodenal Hematoma

We describe an interesting case of intramural duodenal hematoma in an otherwise healthy male who presented to emergency room with gradually progressive abdominal pain, nausea, and vomiting. This condition was missed on initial evaluation and patient was discharged from emergency room with diagnosis of acute gastritis. After 3 days, patient came back to emergency room and abdominal imaging studies were conducted which showed that patient had intramural duodenal hematoma associated with gastric outlet obstruction and pancreatitis. Hematoma was the cause of acute pancreatitis as pancreatic enzymes levels were normal at the time of first presentation, but later as the hematoma grew in size, it caused compression of pancreas and subsequent elevation of pancreatic enzymes. We experienced a case of pancreatitis which was caused by intramural duodenal hematoma. This case was missed on initial evaluation. We suggest that physicians should be more vigilant about this condition.

Intramural duodenal hematoma after upper gastrointestinal endoscopy

Intramural hematoma of the duodenum is a very rare condition. It is mostly seen after blunt abdominal trauma in children. There are only few cases of intramural duodenal hematoma after upper gastrointestinal endoscopy. Most of them are associated with coagulation disorders. The optimal treatment strategy for this condition is still under debate. We present the case of a 21-year-old woman who had undergone an upper gastrointestinal endoscopy for dyspepsia and protracted singultus. Work-up included biopsies. Immediately after the procedure, the patient developed an intramural hematoma causing complete duodenal obstruction. The patient was treated conservatively and recovered within three weeks without any sequelae. Uncomplicated cases of intramural hematoma may be treated conservatively with total parenteral nutrition, fluid and electrolyte replacement.

A Case of Intramural Duodenal Hematoma Accompanied by Acute Pancreatitis Following Endoscopic Hemostasis for Duodenal Ulcer Bleeding

Intramural duodenal hematoma is an uncommon condition, which usually develops after blunt abdominal trauma. It is also reported as a complication of anticoagulant therapy, blood dyscrasia, pancreatic disease, and diagnostic and therapeutic endoscopy. The typical clinical pictures of intramural duodenal hematoma consist of upper abdominal pain, vomiting, fever, and hematochezia, and it is rarely accompanied by intestinal obstruction, peritonitis, and pancreatitis as its complication. We report a case of intramural duodenal hematoma extended to peritoneal cavity, and accompanied by acute pancreatitis following therapeutic endoscopy for duodenal ulcer bleeding in a 32-year-old man who was on maintenance of anti-coagulation therapy after valvular heart surgery.

Duodenal hematoma in infancy and childhood: Changing etiology and changing treatment

It is estimated that between 2300,000 and 4,000,OOO cases of active child abuse occur in the United States annually [I], and estimated deaths due to child abuse vary from 2,000 [2] to 50,000 annually [I]. The extreme variation in estimates is due to the difficulties inherent in proving or disproving child abuse. The child is either too young to testify on his own behalf or too frightened to do so. The abusive adult is not apt to admit to the abusive act, and those who live with him or her will assume a protective posture toward the abuser, thus denying all such allegations. Although the number of reported cases of intramural duodenal hematoma is increasing, there has been no consistent reportage of the association of active child abuse with this injury. Some of the case reports indicate “trauma of unknown etiology.” Such injuries may, in retrospect, be due to child abuse [3-81. In 1969 we reported our experience with seven patients who were treated for intramural duodenal hematoma [9]. Traumatic injury was denied by the parents of one patient, and in another the details of the trauma were not available. In retrospect, these two patients may have been injured by an abusive adult; however, at the time the manuscript was completed none of the patients was recognized as having been actively abused. During the subsequent seven years (1969-1977) eight patients have been treated for duodenal hematoma at the Childrens Hospital of Los Angeles. A retrospective review of these patients forms the basis of the present report.

Intramural hematoma of the duodenum

Five new cases of intramural duodenal hematoma are reviewed with 174 cases derived from the literature. Operative therapy with simple evacuation of the hematoma is advocated as the procedure of choice. Bypass procedures and resection should be reserved for selected cases.

Intramural Hematoma of the Duodenum

Acute obstruction of the duodenum in the second and third parts is infrequent. The commonest causes of such an obstruction are congenital defects of the duodenum and pancreas, anomalies of rotation of the bowel, mesenteric artery syndrome, ulcers, neoplasms of the ampulla of Vater and duodenum, gallstones and foreign bodies, and invasive tumors of surrounding organs. Duodenal obstruction due to intramural hematoma was practically unknown until rather recently. The first report of a case of duodenal obstruction due to intramural hematoma was made by McLauchlan in 1838.8In 1948 Liverud described the x-ray findings of intramural hematoma, and, although in his case the hematoma was in the first part of the jejunum, the x-ray appearance was almost identical with that of intramural hematoma of the duodenum.6 Felson and Levin, in 1954, reported four cases of intramural duodenal hematoma and described in detail the x-ray appearance produced by barium