Intramural Hematoma of the Duodenum A Diagnostic Roentgen Sign

Abstract

Intramural hematoma of the intestine is a condition in which, spontaneously or as a result of trauma, a localized collection of blood extravasates into the subserosal and interstitial tissues of the intestine. It has been described on a number of occasions as an unexpected finding at laparotomy or at autopsy, but a correct preoperative diagnosis has not been recorded. In 1948 Liverud (9) reported a case involving the jejunum adjacent to the ligament of Treitz, and included the only detailed roentgen description in the literature. We have encountered 4 cases, in each of which the duodenum was predominantly affected. The roentgen findings, similar to those in Liverud's case, are so distinctive that we believe them to be pathognomonic of intramural hematoma of the duodenum. Report of Cases Case I: G. D., an 18-year-old male, was admitted to Cincinnati General Hospital on Nov. 17, 1951, seven hours after being struck in the abdomen during a football game. He was momentarily prostrated by the injury, but felt well for the next few hours. Three hours after the injury, persistent dull upper abdominal pain developed, slowly increasing in intensity and accompanied by vomiting. There was no hematemesis or melena. On admission, the temperature was 99°F., and pulse, respirations, and blood pressure were normal. Physical examination was negative except for tenderness in the upper abdomen and right flank. Hemoglobin was 14 gm., the white blood cell count 8,600, and serum amylase 646 Somogyi units. Urine was normal. Flat and upright films of the abdomen on admission showed no free gas. The right psoas shadow was not visualized. Because of the possibility of a ruptured hollow viscus, a small amount of Lipiodol was given by mouth and followed for eight hours. Except for some delay in transit time, no abnormalities were seen. On conservative management, the low-grade fever and epigastric pain persisted. The white count rose to 14,000 and the serum amylase gradually fell to 124 units. On Nov. 21, an upper gastrointestinal series was performed with barium. A small extrinsic defect on the greater curvature of the gastric antrum was noted, and the mucosal folds in the proximal duodenum appeared thickened. In the distal duodenum, near the ligament of Treitz, an intramural extramucosal type of defect was seen. The valvulae conniventes in this region were crowded together (Fig. 1, A and B). The roentgen findings were attributed to intramural inflammation or hemorrhage secondary to acute traumatic pancreatitis, possibly with perforation into the duodenum. The examination was repeated on Nov. 25 with similar findings. Surgical exploration was undertaken on Nov. 27. A subserosal hematoma 20 cm. in length was found in the distal duodenum and proximal jejunum. There was also a large hematoma in the adjacent retroperitoneal space. The two hematomas communicated and together contained about 600 c.c. of liquid and clotted blood.