Gastrointestinal: Intramural hematoma of the duodenum

Abstract

An intramural hematoma of the duodenum was first reported in an article in the Lancet in 1838. At least 90% of cases are caused by blunt abdominal trauma, typically accidents involving bicycles or motor vehicles. The susceptibility of the duodenum to hematoma formation has been attributed to its position, which is relatively fixed by its retroperitoneal location and relationship to major arteries. In addition, it has a generous blood supply and is partly enclosed by the pylorus and the ligament of Treitz. Hematomas caused by trauma are more common in children than in adults. Rare causes for hematoma formation include bleeding associated with anticoagulant medication and bleeding into the duodenal wall after endoscopic biopsies or endoscopic therapeutic procedures. In relation to clinical features, most patients have abdominal pain as well as nausea and vomiting due to gastric outlet obstruction. A minority have a palpable mass in the right upper quadrant of the abdomen. The diagnosis can be made by barium meal radiographs, abdominal ultrasound studies or computed tomography (CT) scans. Duodenal obstruction resolves spontaneously in most patients with intravenous fluids, nasogastric suction and analgesia. Case reports also describe accelerated recovery after percutaneous aspiration of the hematoma under ultrasound control. The images shown below were from a 39-year-old man who was readmitted to hospital after an endoscopic biopsy of the duodenum with nausea, vomiting and abdominal pain. Figure 1 shows the endoscopic view of the duodenal bulb from the pylorus. The hematoma was seen as a large, violaceous mass obstructing the duodenal bulb. The diagnosis was confirmed by a CT scan that showed a 5 × 4 cm hyperdense mass (H) obstructing the second part of the duodenum (Fig. 2). Various tests of coagulation were normal. The patient was treated conservatively and the size of the mass was followed by serial ultrasound studies. He was able to resume oral feeding after 1 week.