CASE 17129 Published on 20.01.2021

Intramural duodenal hematoma of the duodenum in non-accidental trauma

Section

Paediatric radiology

Case Type

Clinical Cases

Authors

Sebastian Duque Yemail1, Julio Pérez González2, Micaela Germani3, Alejandro Moujir Sanchez2, German E. Menapacce Granada4

1. Hospital Universitario de Gran Canaria Doctor Negrín, radiology department, Las Palmas de Gran Canaria, Spain.

2. Complejo Hospitalario Universitario Insular Materno Infantil, pediatric radiology department, Las Palmas de Gran Canaria, Spain.

3. Complejo Hospitalario Universitario Insular Materno Infantil, pediatric surgery department, Las Palmas de Gran Canaria, Spain.

4. Hospital Doctor Jose Molina Orosa, radiology department, Lanzarote, Spain.

Patient

7 years, male

Categories
Area of Interest Emergency, Gastrointestinal tract, Paediatric ; Imaging Technique CT
Clinical History

7-year-old male patient who consulted for emesis and abdominal pain of two days after abdominal trauma. 

Physical examination revealed multiple bruising of different stages of evolution located in the neck, arms, thorax, abdomen, back and thighs. Of note, the parents claimed they were unaware of these injuries.

His hospital course was complicated by multiorgan failure and with the CT findings surgery was required.

Afterwards, with careful history taking and given the lack of explanation for the injuries, non-accidental injury was considered as the etiology of the child trauma.

Imaging Findings

Abdominal CT with intravenous iodinated contrast media showed a high-density fluid of approximately 60 HU located in the duodenal wall convexity, associated with free fluid and signs of intestinal obstruction and telescoping (fig 1a and 1b).

The patient was taken to the OR where it was identified that the third distal segment of the duodenum harbored a mural haematoma with an associated intussusception (fig 2).

Discussion

Duodenal intramural hematoma is a rare entity, representing less than 5% of the pediatric intraabdominal injuries of traumatic nature. Nevertheless, it is the most common mechanism of duodenal injury in children younger than 5 years of age [11], which has been linked to non-accidental trauma [2, 8-11].

Clinical findings are usually subtle and non-specific, and depend on the severity of the duodenal injury. Therefore, this entity is a diagnostic challenge, specially in the setting of nonaccidental trauma in children, given that these patients present to the emergency department with a delayed and poorly dened illness, lack of external abdominal bruising and no history of previous trauma [13, 12, 15]. For this reason, the radiologist has an important role in the diagnosis of intramural duodenal hematoma and child abuse.

Radiological findings depend on the stage of the hematoma and the time of consultation since the event [1]. Usually, ultrasound is used as first line diagnostic modality, as it does not involve ionizing radiation, and it is the most appropriate tool in the setting of a hemodynamically unstable patient. However, the radiologist must take into consideration its limitations in the assessment of abdominal trauma, bone lesions and low sensitivity in hollow viscus injury [16]. Nevertheless, ultrasound will show an echogenic mass in the duodenal convexity or oftentimes only wall thickening is seen [5, 6].

CT imaging is the modality of choice in abdominal trauma[16]. It reveals a homogeneous mass of 50-60 HU in the duodenal wall, that can be associated with intestinal obstruction signs [1,3,4,6]. Additionally, CT imaging has treatment value by stratifying patients based on the duodenal injury scale of the AAST, assessing any other solid organ injury, fractures and spine lesions, and ruling out perforation, providing the surgeon with criteria to determine whether surgical or conservative treatment is warranted [7].

In addition to CT, and depending on specific protocols from different institutions, magnetic resonance imaging (MRI) can be used to assess pediatric abdominal trauma without the risk of radiation and with the advantage of contrast and soft tissue resolution [17]. MRI also allows to determine temporal stages of lesions by assessing the hematoma signal changes of the stages of an evolving hematoma (hyperacute, acute, subacute, chronic) [6,14,17].

As previously mentioned, imaging studies play an important role in treatment, which will determine the severity of the findings and the clinical stability of the patient. Bowel rest and nutritional support is the cornerstone of conservative treatment, while surgical intervention is required in high grade intestinal obstruction or bowel perforation [3,7].

Teaching points

  • Duodenal injury in children must always raise concern for non-accidental trauma. 
  • US can be used as a first-line modality of study, however, CT imaging or MRI should be considered in specific cases, especially in inconclusive findings or to determine surgical treatment or not.
  • CT images are going to show a homogeneous mass of 50-60 HU in the duodenal wall and helpful to discard perforation.

 

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Intramural duodenal hematoma secondary to non-accidental trauma
Small bowel intussusceptions
Midgut volvulus
Intramural duodenal hematoma for accidental trauma
Bowel injury due to non-accidental trauma
Duodenal hemorrhage due to blood dyscrasias
Bowel obstruction
Final Diagnosis
Intramural duodenal hematoma secondary to non-accidental trauma
Case information
URL: https://www.eurorad.org/case/17129
DOI: 10.35100/eurorad/case.17129
ISSN: 1563-4086
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