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A Rare Cause of Obstructive Jaundice
Clinical Challenges and Images in GI David A. Katzka and David L. Jaffe, Section Editors
A Rare Cause of Obstructive Jaundice
See related article, Jongwutiwes U et al, on page xxxii in CGH. Question: An 80-year-old woman was admitted to the hospital because of jaundice, upper abdominal pain, nausea, and vomiting. The patient was on phenprocoumon for chronic atrial fibrillation. Physical examination revealed right upper quadrant tenderness and jaundice. Laboratory studies revealed abnormal coagulation tests with a prolonged prothrombin time (International Normalized Ratio ⬎6.0) and a prolonged activated partial thromboplastin time (⬎110 seconds). Furthermore, her liver chemistry tests were abnormal with total bilirubin at 12 mg/dL, alanine aminotransferase at 170 U/L, aspartate
GASTROENTEROLOGY 2009;137:40 – 42
aminotransferase at 230 U/L, and alkaline phosphatase at 1050 U/L. Her hemoglobin was 10 g/dL with a normocytic anemia blood picture. Abdominal ultrasonography was performed and showed ballooning of the gallbladder with wall thickening, dilatation of the common bile (9 mm), and pancreatic duct (6 mm). A further pathologic finding was also demonstrated dorsal to the pancreas on ultrasonography (Figure A, arrow). On endoscopic retrograde cholangiopancreatography, no stones could be identified in the biliary passages. Abdominal computed tomography (Figure B, arrow) and magnetic resonance imaging (Figure C, arrow) were performed demonstrating abnormal findings. What is the diagnosis? Look on page 394 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. AHMED ABDEL SAMIE, MD RUI SUN, MD LORENZ THEILMANN, MD Department of Internal Medicine and Gastroenterology Pforzheim Hospital Pforzheim, Germany
Conflicts of interest The authors disclose no conflicts. © 2009 by the AGA Institute 0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.12.063
394
CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 137, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 40): Obstructive Jaundice Owing to Spontaneous Duodenal Hematoma Complicating Anticoagulant Therapy Ultrasonography demonstrated a heterogeneous mass within the duodenal wall. Computed tomography confirmed these findings, showing circumferential wall thickening and luminal narrowing of the descending duodenum consistent with intramural hematoma. On MRI, a well-defined concentric ring configuration (ring sign) was detected, a finding that helped to establish the diagnosis. This unique MRI tissue characteristics (ring with short T1 and long T2 relaxation times) are attributable to the paramagnetic properties of iron species within the hematoma. Phenprocoumon therapy was stopped and the patient was treated conservatively with vitamin K and fresh frozen plasma. Early, noninvasive diagnosis by ultrasonography and computed tomographic scan was possible. Conservative therapy proved successful in complete resolution of obstructive symptoms. Duodenal hematoma is an unusual condition. At least 90% of cases are caused by blunt abdominal trauma, typically accidents involving bicycles or motor vehicles. Intramural duodenal hematoma is a rare complication of anticoagulant therapy. It occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factor for bleeding.1 It can lead to biliary obstruction and pancreatitis, and there are no definite guidelines for its management. Proper management of duodenal hematoma requires that an accurate diagnosis be made using noninvasive methods. Ultrasonography, computed tomography, and magnetic resonance imaging are useful in diagnosing duodenal hematoma, excluding accompanying lesions, and monitoring resolution with conservative treatment. This rare condition can be readily identified with bedside sonography2 and confirmed with computed tomography, which is invaluable in detecting the abnormality and can be diagnostic. Early diagnosis is crucial because most patients can be treated nonoperatively with a good outcome.3 Based on this experience and that obtained in the review of the literature, conservative treatment is recommended for intramural duodenal hematomas, when other associated problems needing a laparotomy have been excluded. References 1. Sirvain S, Crepeau T, Garrido JF, et al. Anticoagulant induced intramural duodenal hematoma presenting as duodenal obstruction. Gastroenterol Clin Biol 2008;32:611– 613. 2. Hou SW, Chen CC, Chen KC, et al. Sonographic diagnosis of spontaneous intramural small bowel hematoma in a case of warfarin overdose. J Clin Ultrasound 2008;36:374 –376. 3. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389 –1394. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
A Rare Cause of Obstructive Jaundice
See related article, Jongwutiwes U et al, on page xxxii in CGH. Question: An 80-year-old woman was admitted to the hospital because of jaundice, upper abdominal pain, nausea, and vomiting. The patient was on phenprocoumon for chronic atrial fibrillation. Physical examination revealed right upper quadrant tenderness and jaundice. Laboratory studies revealed abnormal coagulation tests with a prolonged prothrombin time (International Normalized Ratio ⬎6.0) and a prolonged activated partial thromboplastin time (⬎110 seconds). Furthermore, her liver chemistry tests were abnormal with total bilirubin at 12 mg/dL, alanine aminotransferase at 170 U/L, aspartate
GASTROENTEROLOGY 2009;137:40 – 42
aminotransferase at 230 U/L, and alkaline phosphatase at 1050 U/L. Her hemoglobin was 10 g/dL with a normocytic anemia blood picture. Abdominal ultrasonography was performed and showed ballooning of the gallbladder with wall thickening, dilatation of the common bile (9 mm), and pancreatic duct (6 mm). A further pathologic finding was also demonstrated dorsal to the pancreas on ultrasonography (Figure A, arrow). On endoscopic retrograde cholangiopancreatography, no stones could be identified in the biliary passages. Abdominal computed tomography (Figure B, arrow) and magnetic resonance imaging (Figure C, arrow) were performed demonstrating abnormal findings. What is the diagnosis? Look on page 394 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. AHMED ABDEL SAMIE, MD RUI SUN, MD LORENZ THEILMANN, MD Department of Internal Medicine and Gastroenterology Pforzheim Hospital Pforzheim, Germany
Conflicts of interest The authors disclose no conflicts. © 2009 by the AGA Institute 0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.12.063
394
CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 137, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 40): Obstructive Jaundice Owing to Spontaneous Duodenal Hematoma Complicating Anticoagulant Therapy Ultrasonography demonstrated a heterogeneous mass within the duodenal wall. Computed tomography confirmed these findings, showing circumferential wall thickening and luminal narrowing of the descending duodenum consistent with intramural hematoma. On MRI, a well-defined concentric ring configuration (ring sign) was detected, a finding that helped to establish the diagnosis. This unique MRI tissue characteristics (ring with short T1 and long T2 relaxation times) are attributable to the paramagnetic properties of iron species within the hematoma. Phenprocoumon therapy was stopped and the patient was treated conservatively with vitamin K and fresh frozen plasma. Early, noninvasive diagnosis by ultrasonography and computed tomographic scan was possible. Conservative therapy proved successful in complete resolution of obstructive symptoms. Duodenal hematoma is an unusual condition. At least 90% of cases are caused by blunt abdominal trauma, typically accidents involving bicycles or motor vehicles. Intramural duodenal hematoma is a rare complication of anticoagulant therapy. It occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factor for bleeding.1 It can lead to biliary obstruction and pancreatitis, and there are no definite guidelines for its management. Proper management of duodenal hematoma requires that an accurate diagnosis be made using noninvasive methods. Ultrasonography, computed tomography, and magnetic resonance imaging are useful in diagnosing duodenal hematoma, excluding accompanying lesions, and monitoring resolution with conservative treatment. This rare condition can be readily identified with bedside sonography2 and confirmed with computed tomography, which is invaluable in detecting the abnormality and can be diagnostic. Early diagnosis is crucial because most patients can be treated nonoperatively with a good outcome.3 Based on this experience and that obtained in the review of the literature, conservative treatment is recommended for intramural duodenal hematomas, when other associated problems needing a laparotomy have been excluded. References 1. Sirvain S, Crepeau T, Garrido JF, et al. Anticoagulant induced intramural duodenal hematoma presenting as duodenal obstruction. Gastroenterol Clin Biol 2008;32:611– 613. 2. Hou SW, Chen CC, Chen KC, et al. Sonographic diagnosis of spontaneous intramural small bowel hematoma in a case of warfarin overdose. J Clin Ultrasound 2008;36:374 –376. 3. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002;179:1389 –1394. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).