Teaching Case

An 8-year-old female patient presented to the Emergency department with abdominal pain and nausea following a fall from a bicycle and trauma with the handlebar.

Contrast-enhanced CT of the abdomen in an axial plane (Fig. 1a) demonstrates a well-defined hypodense mass consistent with duodenal wall thickening (yellow arrow) with no signs of contrast media extravasation.

Red arrows in CT reconstruction images in a coronal (Fig. 2a) and sagittal plane (Figure 3a) allow a better analysis of the low density areas involving the second and third portions of the duodenum consistent with intramural haematoma. Note how there is also widening of the aorto-mesenteric angle.

Intramural haematomas of the gastrointestinal tract are rare and can develop along any part from the esophagus to the rectum, with the duodenum being the most common portion involved [1]. Children are the most common population to develop this lesion, frequently as a result of blunt trauma (70%). Due to its retroperitoneal location, duodenal haematomas occur in only 3–5% of all patients with trauma-related abdominal injuries [2]. Children are at greater risk of duodenal injury from blunt trauma due to their reduced protection from abdominal fat and the costal margins which are more horizontal [3].

A retrospective chart review in two large paediatric trauma centers found non-accidental injury as the number one cause of duodenal injury, with bicycle accidents being the third most common cause [4].

Due to its retroperitoneal location, duodenal haematoma may present with vague, nonspecific, insidious abdominal pain with nausea or vomiting [4, 5]. Diagnosis remains a challenge, and plain radiographs often lack free air from perforation. Abdominal CT scan IV contrast is an important diagnostic tool for duodenal injuries [3, 6].

On CT, a heterogeneous or high attenuation mass may be seen along the wall of the duodenum, or diffuse wall thickening may be seen that can lead to proximal obstruction [7, 8]. Extraluminal fluid without signs of solid organ injury can be seen as well [8]. Evidence of free air or extravasated contrast is an indication for emergency surgery [4]. Ultrasound will show a hypoechoic mass near the pancreas [7]. Injuries are classified according to the Organ Injury Scale for the Duodenum based on CT findings [9].

Management has traditionally been nonoperative, including bowel rest, nasogastric decompression, peripherally-inserted central catheter placement, and parenteral nutrition. The length of stay can vary considerably, and enteral nutrition is resumed when gastric aspirates are no longer bilious [3]. Patients presenting with haemodynamic instability or signs of perforation require emergency operative intervention. Other therapies include percutaneous or operative drainage of the haematoma [3].

Duodenal haematoma in children is primarily caused by blunt trauma, doesn't usually require surgery and has a low mortality if diagnosed and managed promptly [3, 8].
Delays in diagnosis can lead to increased length of stay and overall complication rates, thus fast diagnosis is essential [3, 4].

Written informed patient consent for publication has been obtained.