Preoperative diagnosis ofintramural duodenal hematoma

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Brief clinical and laboratory observations

injected from the retroplacental or retromembranous tissues as the head progresses down the cervical canal. This will occur even more easily if fetal distress is present and respiratory movements are starting. A few cubic centimeters of blood suffice to fill the lungs of a newborn baby; the lungs in this particular infant weighed 27 and 25 grams, so that less than 30 c.c. could account for all the blood encountered in the alveolar spaces. SUMMARY A case of massive pulmonary hemorrhage in the newborn is presented. Due to the fact that the mother had a hemoglobinopathy (A-S) that modifies the shape of the red blood cells in low 0 2 tension (as in formalin fixation), it was possible to establish very definitely the etiology of the process as resulting from aspiration of maternal blood by the baby during delivery. This observation

Preoperative diagnosis of intramural duodenal bematoma R. E. D a r b y , Captain, M C , USA,* H. F. Johnson, Major, M C , USA,** and E. W. Till, Captain, M C , U S A FORT GORDON,

OA.

From the Radiology Service United States Army Hospital Specialized Treatment Center. This material has been received by the O~ice of The Surgeon General, Department o[ the Army, and there is no objection to its presentation and publication. This review does not imply any indorsement o[ the opinions advanced or any recommendation of such products as may be named. *Present address, Hinsdale Sanitarium and Hospital, 120 North Oak St., Hinsdale, Ill., 60521. e'e'Present address, TamOa General Host)itat, Davis Islands, Tampa, Fla. 33602.

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shows clearly that aspiration of maternal blood m a y be a cause of so-called massive pulmonary hemorrhage in the newborn, and that this pathogenic mechanism should be investigated seriously in any future study of the condition. REFERENCES

1. Esterly, J., and Oppenheimer, E. H.: Massive pulmonary hemorrhage in the newborn. I. Pathologic considerations, J. PEI~IAT. 69: 3, 1966. 2. Rowe, D. S., and Avery, M. E.: Massive pulmonary hemorrhage in the newborn. II. Clinical considerations, J. PEDIAT. 69: 12, 1966. 3. Driscoll, S. G., and Smith, C. A.: Neonatal pulmonary disorders, Pediat. Clin. North America 9: 325, 1962. 4. Ahvenainen, E. K., and Call, J. D,: Pulmonary hemorrhage in infants, a descriptive study, Am. J. Path. 28: 1, 1952. 5. Ahvenainen, E. K.: Massive pulmonary hemorrhage in newborns, Ann. paediat. Fenniae. 2: 44, 1956. 6. Potter, E. L.: Pathology of the fetus and the infant, ed. 2, Chicago, 1961, Year Book Medical Publishers, Inc., p. 298.

A P P R O X I M A T n L Y 98 cases of intramural duodenal hematoma have been reported. 1-s A definite history of trauma was elicited in 77 cases, while the remainder had a questionable or unreliable history of injury. Only 13 of the last 24 reported cases were diagnosed preoperatively, x, 2, ,-s I n this article are reported two additional patients in w h o m the preoperative diagnosis of intramural duodenal h e m a t o m a was made. CASE R E P O R T S Case 1. M. G., a 9-year-old female patient, was hospitalized on April 16, 1966, with a history of vomiting for two days. Three days prior to admission she sustained a blunt blow to the abdomen, striking the dashboard of an automobile which stopped suddenly. At the time of the mishap the patient also suffered minor abrasions and contusions of the face, hips, and extremities. Physical examination revealed a normal temperature, pulse 110, and respirations 22 per minute. Mild tenderness of the epigastrium was present and the bowel sounds were normal. The

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The Journal o[ Pediatrics March 1968

Fig. 2. Patient in Case 2. Upper gastrointestinal study performed 8 days following a blow to the abdomen. Note the sharply circumscribed eccentric narrowing in the second part of the duodenum.

Fig. 1. Patient in Case I. Upper gastrointestinal study performed 13 days following blunt trauma to the upper abdomen demonstrates eccentric narrowing of the lumen in the second and third portions of the duodenum.

patient was moderately dehydrated. The hematocrit was 40 per cent and the white blood cell count was I 1,200 per cubic millimeter. Urinalysis was normal. Following admission the patient vomited bilestained material although receiving nothing by mouth, and intravenous fluid therapy was begun. A repeat hematocrit was 31 per cent following hydration. On April 20, 1966, an upper gastrointestinal series indicated gastric dilation and narrowing of the second and third portions of the duodenum (Fig. 1) characteristic of an intramural duodenal mass. The serum amylase, performed two days later, was 360 Somogyi units. A repeat upper gastrointestinal study on April 26, 1966, again demonstrated the intramural defect of the duodenum and the diagnosis of intramural duodenal hematoma was made. Laparotomy was performed on April 27, 1966, and a blood clot, 60 cu. cm., was enucleated from the duodenal wall. The patient was discharged on the seventh postoperative day. On May 18,

1966, a follow-up gastrointestinal series was normal. Case 2. J. G., a 4-year-old female patient, was admitted to the hospital on March 4, 1967, with marked dehydration and thirst. The patient had vomited during the 3 days prior to admission. Physical examination revealed a dry mouth, sunken eyes, and extreme loss of skin turgor. The temperature was 103 ~ F. and the pulse, 180 per minute. Laboratory studies included: hematocrit, 37 per cent; hemoglobin, 12.8 Gin. per cent; white blood count, 12,500 per cubic millimeter with a normal differential count; normal serum electrolytes; and a urinalysis with a specific gravity of 1.012, 5 to 8 white blood cells and 6 to 8 red blood cells per high powered field. The chest roentgenogram was normal. While the patient received intravenous fluids, the vomiting began to subside but was noted to be bile stained. Further questioning revealed that she had been hit in the abdomen by a playmate prior to the onset of illness. An upper gastrointestinal series on March 8, 1967, revealed an intramural defect in the second portion of the duodenum (Fig. 2). The diagnosis of an intramural duodenal hematoma was made. At surgery on March 9, 1967, a partially organized hematoma, 25 cu. cm., was evacuated from the submucosal layer of the descending portion of

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the duodenum. The patient improved rapidly during the next 5 days and was discharged. On April 29, 1967, a follow-up gastrointestinal study indicated the duodenum to be within normal limits. ETIOLOGY The fixed position of the duodenum in relation to the paravertebral structures makes it more susceptible to direct trauma than is the remainder of the intestinal tract. Intramural hematoma of the duodenum results from trauma to the upper abdomen, producing a shearing force in which the duodenum is compressed against the vertebral column. 9 The majority of cases reported have occurred either in children or alcoholics suggesting that relaxation of the abdominal musculature is a necessary prerequisite. Commonly, there is a delay in the onset of symptoms and physical findings which is most likely related to subsequent enlargement of the hematoma. CLINICAL FINDINGS A history of blunt trauma to the abdomen can usually be elicited. Occasionally, no history of trauma is obtained because the patient is too young to provide it or is incapable or unable to recall a specific incident. Cases with no history of trauma may be associated with a hemorrhagic diathesis secondary to either a primary hematological abnormality or excessive anticoagulation therapy. Symptoms of abdominal pain, nausea, and vomiting may be initially absent or minimal but, within several days, tend to become progressively more severe. The abdominal pain may be generalized or localized to the epigastric and periumbilical areas. The vomitus is often bile stained. Physical examination usually demonstrates tenderness of the abdomen. Marked retroperitoneal hemorrhage may give rise to a palpable epigastric mass or doughy bulging of the flanks. If vomiting has been marked or prolonged, dehydration will be evident. Vital signs are generally within normal limits. Laboratory studies usually reveal an elevated white blood count; the hemoglobin and hematocrit may be slightly decreased.

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The urinalysis is almost always within normal limits. An elevated serum amylase is frequently associated with observations of pancreatic hemorrhage and/or fat necrosis at operation. RADIOLOGICAL FINDINGS

Plain radiographic studies of the abdomen may demonstrate a dilated stomach and proximal part of the duodenum without significant gas in the more distal portions of the gastrointestinal tract, suggesting obstruction in the distal duodenum. A poorly defined or absent right psoas shadow suggests an associated retroperitoneal abnormality. Contrast studies of the upper gastrointestinal tract demonstrate a characteristic eccentric narrowing of the duodenum, indicating the presence of an intramural mass. This narrowing may extend the entire length of the duodenum and include some of the jejunum near the ligament of Trietz or the distal part of the stomach. However, the second and third portions of the duodenum are more often involved. Proximal to the intramural defect, retained gastric secretions, slow passage of the contrast material from the stomach into the duodenum and slight dilatation of the stomach and proximal part of the duodenum are encountered. The mucosal pattern is prominent as the folds of mucosa tend to stretch over and partially surround the intramural hematoma, resembling, but not identical to the "coiled spring" appearance of a typical intussusception of the small bowel or colon. Traumatic intramural duodenal hematomas are almost always solitary, relatively large, often causing almost complete obstruction. On the other hand, intramural defects associated with defects of coagulation are generally multiple, relatively small, rarely cause obstruction, and are scattered over more extensive segments of small intestine and colon. TREATMENT

Evacuation of the hematoma is the treatment of choice in most instances. This is accomplished by a subserosal approach to the

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duodenal wall whereby the clot may be aspirated or enucleated without entering the lumen of the duodenum. Bypass surgical procedures should be reserved for those cases in which marked retroperitoneal hemorrhage and deformity have occurred in addition to the intramural duodenal abnormality. In such instances, the tissues of the involved areas are friable or the tissue viability is threatened. Several cases of intramural h e m a t o m a of the d u o d e n u m have been observed to resolve without surgical intervention. This conservative approach may be warranted in selected patients if symptoms and physical findings are mild. However, recovery is dramatic, rapid, and usually complete when the hematoma is removed surgically. SUMMARY T w o cases of intranmral duodenal hematoma are presented in which the diagnosis was made preoperatively. Intramural hematomas of the d u o d e n u m are occasionally the sequelae of direct trauma to the upper abdomen in children. T h e correct diagnosis can be suspected clinically and confirmed radio-

Wilms" tumor in bone marron, aypirate

Peggy O'Neill, B.S., M.T. ( A S C P ) , and Donald Pinkel, M.D. MEMPI{IS, TENN.

From the St. Jude Children's Research Hospital and University o[ Tennessee Department of Pediatrics. Supported by United States Public Health Service Research Grant CA 08480 from the National Cancer Institute and American Lebanese Syrian Associated Charities (ALSAC).

The Journal o/ Pediatrics March 1968

graphically. Surgical removal of the hematoma is the treatment of choice. The authors wish to thank Arthur E. McElfresh, M.D., for his review and helpful suggestions in the preparation of this article. REFERENCES 1. Devroede, G. J., Tirol, F. T., La Russo, V. A., and Narducci, A. E.: Intranmral hematoma of the duodenum, Am. J. Surg. 112: 947, 1966. 2. Farman, J., Stein, D., and Krige, H.: Duodenal hematoma, Clin. Radiol. 17: 177, 1966. 3. Freeark, R. J., Corley, R. O., Norcross, W. J., and Srohl, E. L.: Intramural hematoma of the duodenum, Arch. Surg. 92: 463, 1966. 4. Hill, M. C.: Roentgen diagnosis of duodenal injuries, Am. J. Roentgenol. 94: 356, 1965. 5. Mathewson, C. M., Jr., and Morgan, R.: Intramural hematoma of the duodenum: A clinical entity, Am. J. Surg. 112: 299, 1966. 6. Steger, B., and Worley, J. W.: Intramural hematoma of the duodenum, J. Lancet 85: 495, 1965. 7. Tobin, J. J., Jr., Schland, H. A., and James, D. R.: Intramural hematoma of the duodenum associated with peroral small-bowel biopsy, J. A. M. A. 198: 786, 1966. 8. Well, A. J., and Taylor, J. J.: Traumatic intramural haematoma of the duodenum, Brit. J. Surg. 54: 50, 1967. 9. Williams, R. D., and Sargent, F. T.: Mechanisms of intestinal injury in trauma, J. Trauma 3: 288, 1963.

ALT~OUO~ detection of bone marrow infiltration with tumor by routine aspiration is c o m m o n with neuroblastoma, this has not been reported with Wilms' tumor. Indeed it has been suggested that the presence of tumor ceils in the m a r r o w is one w a y to differentiate neuroblastoma from Wilms' tumor in the child with an undiagnosed abdominal neoplasm? Recently., we observed a child with typical Wilms' tumor who developed bone m a r r o w metastasis which was detected by routine aspiration of the iliac crest. Prior to admission to this hospital, this 2 89 boy was found to have a mass in the right upper q u a d r a n t of the abdomen. Right nephrectomy and adrenalectomy with partial hepatic resection were performed elsewhere and sections revealed Wilms' tumor