Intramural duodenal haematoma secondary to blunt abdominal trauma

Clinical History

We report a case of a 20-year-old female patient presenting at our emergency department with acute abdominal pain following a high-speed road traffic accident.

Imaging Findings

Although young, this patient had a background history of excess alcohol intake. Otherwise, there was no other relevant history.

An initial erect chest and abdominal X-ray werw performed, which were normal, and subsequently the patient was referred for a computed tomography (CT) examination of abdomen and pelvis.

CT showed significant mural thickening of the second and third part of the duodenum which was of higher attenuation than that of soft tissue, consistent with a duodenal intramural haematoma (HU 65-69). No retroperitoneal free gas, free fluid or contrast extravasation was demonstrated to suggest a duodenal perforation.

Incidental note was made of specks of parenchymal calcification within the pancreas representing chronic or previous episodes of pancreatitis and diffuse low-attenuation change in the liver representing fatty change.

Patient was initially considered for surgical drainage but did respond to conservative management and no further imaging was deemed clinically necessary.

Discussion

Intramural duodenal haematoma is an uncommon injury. 90% of cases are associated with blunt abdominal trauma [1,2] and the morbidity and mortality range from 6 to 25% [3,4]. Non-traumatic causes of intramural duodenal haematoma include anticoagulant therapy, bleeding disorders, and haematomas associated with endoscopic biopsies or interventions [1,5].

With growing use of MDCT in trauma situations and an increase in awareness, intramural duodenal haematomas are being recognised more commonly [5,6]. The relatively fixed retroperitoneal location between the pylorus and ligament of Treitz and its high vascularity explains the susceptibility of the duodenum to trauma and haematoma formation. Traumatic injuries range from minor intramural haematoma, partial-thickness to extensive disruption of the duodeno-pancreatic complex [6].

Clinical diagnosis of intramural duodenal haematoma is difficult and often delayed [2,7].
Associated pancreatitis is seen in up to 40% of patients secondary to direct pancreatic trauma at the time of injury or obstruction of ampulla of Vater by haematoma [6,8].

The diagnosis of intramural duodenal haematoma is suspected from plain radiograph and ultrasound but generally confirmed by CT.
Plain radiograph shows distension of the stomach with or without distension of duodenum producing a “double bubble” appearance [7]. Upper GI barium series shows a “coiled spring” appearance or complete obstruction [7].
Ultrasound shows a hypoechoic mass in the region of the pancreas depending upon the stage of the haematoma and may resemble pancreatic pseudocyst [9].

MDCT without oral contrast is the primary imaging modality in trauma [10]. The findings of intramural haematoma include wall thickening, heterogeneous attenuation in the wall, periduodenal fluid, fluid in the anterior pararenal space, and varying degree of proximal obstruction [6,11].
The strength of CT is to be able to differentiate between duodenal haematoma and duodenal perforation since the latter requires prompt surgical intervention while the former is managed conservatively [6]. Duodenal perforation is associated with extraluminal retroperitoneal and/or intraperitoneal gas and extravasation of oral contrast (if used). Neither of these is seen with intramural haematoma of the duodenum. While reviewing the CT it is also important to exclude associated retroperitoneal solid organ injuries [6].
MRI appearance of intramural duodenal haematoma is variable. A central low signal surrounded by an inner hyperintense (methaemoglobin) and outer hypointense (haemosiderin) ring (“concentric ring” sign) is typically seen in haematomas older than 3 weeks, whereas thew appearance between 1-3 weeks is variable [12,13].

Intramural duodenal haematoma is usually managed conservatively with intravenous fluids, nasogastric suction and analgesia. Surgery is generally reserved for patients in whom conservative management fails [1,7].

Differential Diagnosis List

Final Diagnosis

Intramural duodenal haematoma secondary to blunt abdominal trauma.

URL:	https://www.eurorad.org/case/9052
DOI:	10.1594/EURORAD/CASE.9052
ISSN:	1563-4086