Texas Tech University Health Sciences Center Lubbock, TX
Alay G. Tikue, MD1, Genanew Bedanie, MD1, Mohamed Zitun, MD1, Passisd Laoveeravat, MD1, Mohamed Elmassry, MD1, Naseem Helo, MD2, Luis Brandi, MD1, Vanessa Costilla, MD2; 1Texas Tech University Health Sciences Center, Lubbock, TX; 2Lubbock University Medical Center, Lubbock, TX
Introduction: Intramural duodenal hematoma (IDH) is hematoma formation within the wall of the duodenum. It commonly occurs secondary to several underlying risk factors, like the use of anticoagulants and antiplatelet drugs or following blunt abdominal trauma. Rarely, it has been reported in relation to acute pancreatitis. We present a case of acute pancreatitis associated with IDH and upper gastrointestinal obstruction.
Methods: A 29-year-old male with a history of heavy alcohol drinking presented to the hospital with epigastric pain, nausea, and vomiting. He drinks 12 oz beer every day for more than ten years. He denied any trauma or use of any drugs. Physical examination revealed normal vital signs, epigastric tenderness without signs of peritonitis. Complete blood counts and coagulation profile were within normal limits. He had transaminitis, elevated alkaline phosphatase, and total bilirubin. Serum lipase was 794 U/L (normal: 13-60). Computed tomography (CT) of the abdomen revealed mild stranding of peripancreatic fat, consistent with mild pancreatitis (figure 1). CT angiogram of the abdomen showed a low attenuating mass extending from the second portion of the duodenum to its fourth part, consistent with an IDH (figure 2). Upper endoscopy showed more than 1 liter of liquid in the stomach, and a 5cm pulsating polypoid duodenal mass causing gastric outlet obstruction. Histology of the duodenal mass revealed extensive mucosal hemorrhage with the focal dilatation of mucosal capillaries. He was conservatively treated with nothing per mouth, nasogastric tube suctioning, IV fluid replacement, and analgesics. Repeat CT scan done 2 months after discharge showed a complete resolution of IDH. Discussion: Discussion Non-traumatic IDH with normal coagulation profile, like our case, is extremely rare. IDH causing acute pancreatitis and gastric outlet obstruction is even more rare. The IDH likely caused obstruction of the ampulla, resulting in acute pancreatitis. Patients usually present with abdominal pain, nausea, and vomiting. The diagnosis is made by a contrast-enhanced CT scan, which is preferred imaging modality for its availability and cost. Treatment is mainly conservative. Surgical intervention is only considered for failed conservative therapy or if there are complications, like bowel perforation, bowel infarction, and/or hemodynamic instability.
Figure 1: Coronal non-contrast images show inflammation surrounding the pancreas (cyan arrows), Intramural duodenal hematoma (red arrows), and duodenal lumen (green arrows).
Figure 2: Axial contrast enhanced image of the abdomen and (B) Sagittal contrast enhanced image of the abdomen. The green arrows delineate the lumen of the duodenum. The red arrows delineate the intramural hematoma of the duodenum with mass effect on the duodenal lumen.
Disclosures: Alay Tikue indicated no relevant financial relationships. Genanew Bedanie indicated no relevant financial relationships. Mohamed Zitun indicated no relevant financial relationships. Passisd Laoveeravat indicated no relevant financial relationships. Mohamed Elmassry indicated no relevant financial relationships. Naseem Helo indicated no relevant financial relationships. Luis Brandi indicated no relevant financial relationships. Vanessa Costilla indicated no relevant financial relationships.