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

No Procedure ; Special Focus Obstruction / Occlusion, Trauma ;

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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 hasbeen 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 deﬁned 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

References

[1] Abbas MA, Collins JM, Olden KW, Kelly KA. Spontaneous Intramural Small-Bowel Hematoma. Archives of Surgery. 2002;137(3). doi:10.1001/archsurg.137.3.306. (PMID: 11888455)

[2] Dye DW, Peretti FJ, Kokes CP. Histologic Evidence of Repetitive Blunt Force Abdominal Trauma in Four Pediatric Fatalities. Journal of Forensic Sciences. 2008. doi:10.1111/j.1556-4029.2008.00883. (PMID: 18808370)

[3] Kunin JR, Korobkin M, Ellis JH, et al. Duodenal injuries caused by blunt abdominal trauma: value of CT in differentiating perforation from hematoma. Am J Roentgenol 1993; 160(6):1221-3. DOI : 10.2214/ajr.160.6.8498221. (PMID: 8498221)

[4] Jayaraman MV, Mayo-Smith WW, Movson JS, Dupuy DE, Wallach MT. CT of the Duodenum: An Overlooked Segment Gets Its Due. RadioGraphics. 2001; 21(suppl_1). doi:10.1148/radiographics.21.suppl_1.g01oc01s147. (PMID: 11598254)

[5] Lorente-Ramos RM, Santiago-Hernando A, Valle-Sanz YD, Arjonilla-Lopez A. Sonographic diagnosis of intramural duodenal hematomas. Journal of Clinical Ultrasound. 1999;27 (4):213-216. doi: 10.1002/(sici)1097-0096(199905)27:4<213::aid-jcu10>3.0.co;2-k. (PMID: 10323195)

[6] Niehues SM, Denecke T, Bassir C, Hamm B, Haas M. Intramural duodenal hematoma: clinical course and imaging findings. Acta Radiologica Open. 2019; 8(4):205846011983625. doi: 10.1177/2058460119836256. (PMID: 31007947)

[7] Peterson ML, Abbas PI, Fallon SC, Naik-Mathuria BJ, Rodriguez JR. Management of traumatic duodenal hematomas in children. Journal of Surgical Research. 2015; 199(1):126-129. doi:10.1016/j.jss.2015.04.015. (PMID: 25976857)

[8] Poole M, Lawson KA, Edwards G, Meyer T, Garcia N. Duodenal Transection in Child Abuse. Journal of Trauma Nursing. 2011; 18 (4):246-248. doi:10.1097/jtn.0b013e31823a4e7d. (PMID: 22157534)

[9] Shah P, Applegate KE, Buonomo C. Stricture of the duodenum and jejunum in an abused child. Pediatric Radiology. 1997; 27 (3):281-283. doi: 10.1007/s002470050125. (PMID: 9126594)

[10] Shilyansky J, Pearl RH, Kreller M, Sena LM, Babyn PS. Diagnosis and management of duodenal injuries in children. Journal of pediatric Surgery. 1997 32 (6): 880-887. Doi: 10.1016/s0022-3468 (97) 90642-4. (PMID: 9200092)

[11] Shilyansky J, Pearl RH, Kreller M, Sena LM, Babyn PS. Diagnosis and management of duodenal injuries in children. Journal of Pediatric Surgery. 1997; 32(6):880-886. doi: 10.1016/s0022-3468(97)90642-4. (PMID: 9200092)

[12] Sowrey L, Lawson KA, Garcia-Filion P, et al. Duodenal injuries in the very young. Journal of Trauma and Acute Care Surgery. 2013; 74(1):136-142. doi:10.1097/ta.0b013e3182788cb2. (PMID: 23271088)

[13] Veldt BJ, Haringsma J, Florijn KW, Kuipers EJ. Coumarin-induced intramural hematoma of the duodenum: Case report and review of the literature. Scandinavian Journal of Gastroenterology. 2010; 46(3):376-379. doi:10.3109/00365521.2010.531484. (PMID: 21073371)

[14] Wood J, Rubin DM, Nance ML, Christian CW. Distinguishing Inflicted versus Accidental Abdominal Injuries in Young Children. The Journal of Trauma: Injury, Infection, and Critical Care. 2005:1203-1208. doi:10.1097/01.ta.0000196437.07011.b1. (PMID: 16385300)

[15] Zhou H, Ma X, Sheng M, Lai C, Fu J. Evolution of intramural duodenal hematomas on magnetic resonance imaging. Pediatric Radiology. 2018; 48(11):1593-1599. doi: 10.1007/s00247-018-4178-9. (PMID: 30109380)

[16] Torba M, Gjata A, Buci S, Troci A, Subashi K. Delayed presentation of blunt duodenal injuries in children. Case report and review of literature. G Chir. 2013 Apr;34(4):122-4. (PMID: 23660164)

[17] Sivit CJ. Imaging children with abdominal trauma. American Journal of Roentgenology. 2009; 192: 1179-1189. doi: 10.2214/AJR.08.2163

[18] Miele V, Piccolo CL, Sessa B, et al. Comparison between MRI and CEUS in the follow-up of patients with blunt abdominal trauma managed conservatively. 2016; 121(1):27-37. doi: 10.1007/s11547-015-0578-1.

Case information

URL:	https://www.eurorad.org/case/17129
DOI:	10.35100/eurorad/case.17129
ISSN:	1563-4086

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Figure 1

CT axial plane showing a mass of high density in the anterior convexity of duodenum (yellow *) consistent with haematoma, divided by an intraluminal liquid, which prolapse inside of a distal segment of the duodenum which suggest the intussusception. Associated with intraperitoneal free liquid (yellow x).

Coronal CT plane showing a high density mass compatible with haematoma in the wall of the 3rd part of the duodenum (yellow *) with retrograde obstruction (yellow +).

Figure 2