Duodenal hematoma refers to hematoma formation in the duodenal wall, as the most common site of intramural hematoma of the gastrointestinal tract.
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Clinical presentation
upper GIT obstruction: occurs in insidious onset at least 48 hours after injury. Nearly one-third of the patients present with obstruction
in setting of blunt abdominal trauma with other abdominal organ injuries
abdominal pain and tenderness
acute pancreatitis and direct hyperbilirubinemia due to obstruction of Ampulla of Vater
Pathology
The duodenojejunal junction at the ligament of Treitz is a preferred site of traumatic intramural hematoma.
Etiology
It occurs in isolation or with other abdominal organ injury. It may occur as a result of traumatic and non-traumatic settings
Traumatic
non-accidental injury to children: representing about 50% of pediatric cases
iatrogenic: during endoscopic duodenal biopsy as a rare complication
Non-traumatic
patients of anti-coagulant treatment
Radiographic features
Ultrasound
US typically reveals a uniform echogenic mass along the duodenal convexity
small intramural hematoma may present as intestinal wall thickening
obstruction of the duodenal lumen
CT
an isolated hematoma will classically have heterogeneous high attenuationat 50–60 HU with narrowing of duodenal lumen
small hematomas appear as thickened duodenal wall
It usually causes narrowing or obstruction of its lumen
the duodenum is dilated proximal to the affected segment
fluid collection without contrast can be seen in both perforation and hematoma
MRI
MRI is used to detect early signs of bile duct dilatation and to exclude secondary pancreatitis
hematomas signals in MRI is similar to cerebral hematomas depending on its age
Treatment and prognosis
Duodenal hematoma is generally a nonsurgical injury. A hematoma in isolation can be treated conservatively: nasogastric tube decompression with resolution expected in 1-3 weeks.
Complications
lumenal narrowing: occlusion or stricture
biliary: pancreatitis and obstructive jaundice
hemodynamic: hemorrhage and shock
Differential diagnosis
-
distinction must be made as it requires immediate surgical management
unfortunately, the distinction is not always easy radiologically and where diagnostic doubt persists, an exploratory laparotomy may be performed
Practical points
search for other abdominal organ injury in setting of trauma: likel pancreatic, splenic, renal and liver injuries
fluid collection without contrast can be seen in both perforation and hematoma. Extravasation of oral contrast and/or extraluminal gas in the retroperitoneum (right anterior pararenal space) are specific for perforation