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Duodenal hematoma in infancy and childhood
SCIENTIFICPAPERS
Duodenal Hematoma in Infancy and Childhood Changing Etiology and Changing Treatment Morton M. Woolley, MD, Los Angeles, California G. Hossein Mahour, MD, Los Angeles, California
Timothy Sloan, MD, Los Angeles, California
It is estimated that between 2300,000 and 4,000,OOO cases of active child abuse occur in the United States annually [I], and estimated deaths due to child abuse vary from 2,000 [2] to 50,000 annually [I]. The extreme variation in estimates is due to the difficulties inherent in proving or disproving child abuse. The child is either too young to testify on his own behalf or too frightened to do so. The abusive adult is not apt to admit to the abusive act, and those who live with him or her will assume a protective posture toward the abuser, thus denying all such allegations. Although the number of reported cases of intramural duodenal hematoma is increasing, there has been no consistent reportage of the association of active child abuse with this injury. Some of the case reports indicate “trauma of unknown etiology.” Such injuries may, in retrospect, be due to child abuse [3-81. In 1969 we reported our experience with seven patients who were treated for intramural duodenal hematoma [9]. Traumatic injury was denied by the parents of one patient, and in another the details of the trauma were not available. In retrospect, these two patients may have been injured by an abusive adult; however, at the time the manuscript was completed none of the patients was recognized as having been actively abused. During the subsequent seven years (1969-1977) eight patients have been treated for duodenal hematoma at the Childrens Hospital of Los Angeles. A retrospective review of these patients forms the basis of the present report. From the Department of Surgery, Childrens Hospital of Los Angeles, and the University of Southern California School of Medicine, Los Angeles, California. Reprint requests should be addressed to Morton M. Woolley, MD. Department of Surgery, Childrens Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, California 90054. Presented at the Forty-Ninth Annual Meeting of the Pacific Coast Surgical Association, Newport Beach, California, February 19-22, 1976.
8
Etiology of Intramural Duodenal Hematoma
Although there are isolated case reports of patients developing duodenal hematoma secondary to blood dyscrasia [3,5,10] or during anticoagulant therapy [II], the majority of patients in all age groups, and practically all of the patients in the infancy and childhood groups, develop intramural duodenal hematoma secondary to blunt abdominal trauma. Williams and Sargent [12] have demonstrated that traumatic intestinal injury is the result of the bowel being crushed between the anterior abdominal wall and the vertebral column rather than by a rapid compression-decompression injury. The duodenum,
gastroduodenal
sup.pancreaticduodenal a.
inf.pancreaticduodenal a. Sup. mesfsteric
a.
Figure 1. The duodenum is relatively fixed close to the vertebral bodies and has a copious blood supply from the superior and inferior pancreatlcoduodenal arteries.
The American Journal of Surgery
Duodenal Hematoma
being relatively fixed, is prone to injury if enough force is applied to the anterior abdominal wall when the muscles are either relaxed or too weak to resist the force of the significant blow. (Figures 1 and 2.) Since the duodenum has a copious blood supply, the injury may cause rupture of blood vessels, resulting in extravasation of blood between the mucosa and serosa. The hematoma then collects additional fluid and gradually compresses the mucosa against the opposite side of the duodenum producing varying degrees of luminal obstruction. (Figure 3.) In the present series, a history of trauma was obtained in all cases. (Table I.) In four of the eight patients, the trauma was due to child battering. In one additional case (case 4) child abuse was suspected because physical examination revealed multiple bruises; however, abuse was not proved beyond doubt. Clinical Course of Patients Historical Information and Symptoms. One of the ubiquitous characteristics of child abuse is a history that is either overtly misleading or covertly in-
consistent. The family structure is frequently unstable, as in the four battered children in the present series. In two, the child had been battered by the mother’s boyfriend. (Table I.) In one instance, the patient was brought to the hospital five days after the alleged injury. Part of the delay may have been due to delayed onset of vomiting, which is characteristic of intramural duodenal hematoma. In addition, parents of battered children frequently procrastinate in seeking medical care for fear of reprisal. If one suspects a traumatic injury as a result of child abuse, the historical factors must be given little, if any, credence. Physical Findings. Tenderness is usually present in the upper abdomen. (Table II.) A well defined abdominal mass is the exception rather than the rule, but occasionally one will perceive a right upper quadrant mass with ill defined borders if the hematoma is of adequate size to be palpated [13]. If there is bowel perforation in association with the hematoma, the predominant findings will be those of peritonitis. (Table II.) Laboratory Findings. The quantity of blood lost into the intramural hematoma may be significant. In five of the eight patients reported on herein, there was a decrease in the level of hemoglobin of 3 gm/lOO
01 Th12
Figure 2.
Blunt force applied to the anterior abdominal wall may result in rupture of the intramural blood vessels lf the force Is not great enough to perforate the bowel.
Volume 136, July 1878
Figure 3. Rupture of the blood vessels resdts in dissection of the tissues wtthin the wall of the duodenum. The mucosa is apposed to the opposite wall of the duodenum, thus resuttlng in varying degrees of obstruction.
Woolley,
TABLE I
Mahour,
Demographic Data on 8 Patients with Duodenal Hematoma
Case
l
Sex/Age
Family Structure
Caucasian
2’
M/2.5
Black
3’ 4
M/1.7 M11.9
Spanish American Spanish American
5 6
M/5 F/2.6
Spanish American Spanish American
7’
Ml4
Caucasian
8
M15.3
Type of Trauma
Parents married, living together, patient adopted at 5 days of age Parents divorced, mother has custody Parents married, living together Natural father in Mexico, patient lives with mother and stepfather Parents married, living together Mother married, but not to patient’s father Parents divorced, mother living with boyfriend Parents married, living together
Battered by parent
Battered by parent Fell against tricycle handlebar Fell from rocking horse (suspected battering but not proved) Fell from tree on doghouse Battered by mother’s boyfriend Battered by mother’s boyfriend Fell on bicycle handlebars
Associated with bowel perforation.
Historical and Phvsical Findings on 8 Patients with Duodenal Hematoma Symptoms
Interval between Trauma and Symptoms
Interval between Trauma and Admission
1
Vomiting
3 days
5 days
2’
Anorexia, abdominal pain, vomiting Vomiting, abdominal pain Vomiting
7
2 days (?)
2.5 days
5.5 days
Vomiting Vomiting, hematemesis Abdominal pain, vomiting Vomiting, abdominal pain
12hr 36 hr
2 days 2.5 days
3-4 hr
15hr
9 hr
24 hr
3’ 4
5 6 7’ 8
l-2
hr
32 hr
Physical Findings Dehydration, multiple bruises, abdominal tenderness, fear, irritability Dehydration, apathetic, generalized abdominal tenderness Lethargic, shock (blood pressure 70/50), abdomen silent and diffusely tender Lethargic, dehydrated, bruises on abdomen, right upper quadrant tenderness Generalized abdominal tenderness Pale, withdrawn, abdominal tenderness, many bruises Diffuse abdominal tenderness, distension, bruises, febrile, acutely ill Epigastric tenderness
Associated with bowel perforation.
TABLE III
Laboratory Data on 8 Patients with Duodenal Hematoma Hemoglobin (gm/lOO ml)
Case
10
Race
Ml.9
Case
l
(yr)
1
TABLE II
l
and Sloan
White Blood Cell Count
Serum Amylase
1 2’ 3’ 4 5 6
13.4 11.1 14.1 12.0 12.2 11.3
decreasing to 8.9 decreasing to 7.7 decreasing to 6.2 decreasing to 9.0 with no significant decrease decreasing to 6.3
26,500 6,600 4,200 14,800 16,200 10,100
390 59 149 62 905 1,695
7’ 8
13.8 with no significant decrease 12.0 to 11.0
5.900 11,200
124 136
Associated
Remarks 2 blood transfusions Blood transfusion to normal hemoglobin No blood given No blood given No blood given No transfusions given. Hemoglobin spontaneously increased to 10.4 at time of discharge No transfusions given No transfusions given
with bowel perforation
The American Journal of Surgery
Duodenal tiematoma
figure 4. Case 6. Roentgenogram revearing complete obstruction of the duodenum due to extensive intramural duodenal hematoma.
ml or more. (Table III.) The white blood cell count was elevated in those patients who had intramural duodenal hematoma but, for some unknown reason, was not elevated in those who had associated bowel perforation. (Table III.) The serum amylase level was elevated in three of the eight patients, indicative of associated traumatic pancreatitis. The patients with traumatic pancreatitis were limited to those without bowel perforation. Roentgenographic Findings. The roentgenographic findings of duodenal hematoma were first described by Felson and Levin [14] in 1954. If the hematoma has progressed to the point of complete obstruction, no contrast medium will pass through the duodenum. (Figure 4.) If the hematoma displaces the mucosa but does not completely obstruct the lumen, there will be evidence of an intramural filling defect which compresses the valvulae conniventes, resulting in a “coiled spring” appearance similar to that of intussusception. (Figure 5.) As the obstructive mechanism is alleviated by resorption of the hematoma, follow-up gastrointestinal studies will reveal eventual disappearance of the hematoma. (Figure 6.) ‘I’hese roentgenographic findings are now recognized to be diagnostic, so that one can depend on the upper gastrointestinal study for definitive diagnosis. Associated Injuries. In three of the eight patients reported on herein, there was perforation of the proximal jejunum or distal duodenum in association
Volume 136, July 1976
Figure 5. (Case 5. Upper gastroirztestinal study showing a filling defect as well as a coiled spring appearance of intramural dwodenaf hematoma.
Figure 6. Case 6. Upper gastrointestinal study two weeks after injwry showing resolution of intramural duodenal hematoma.
with intramural hematoma. (Table IV.) Perforation of the bowel may be either an index of the severity of the blow or perhaps be due to the anatomic location of the injury. The bowel perforations were all very close to the ligament of Treitz, where the duodenum is relatively fixed and close to the vertebral column. Bruises were observed on the children who had been abused. Therapy. The five patients who had an established diagnosis of duodenal hematoma without associated
11
Mahour, and Sloan
Woolley.
TABLE
IV
Clinical Diagnosis
Case 1
2’
3‘
4 5
6
Clinical Course and Follow-Up of 8 Patients with Duodenal Hematoma Diagnosis Defined by
Gastritis and bruising possibly due to blood dyscrasia Perforative appendicitis
Upper gastrointestinal study
Small bowel perforation, possible pancreatitis Duodenal hematoma
Laparotomy
Possible duodenal hematoma, possible traumatic pancreatitis Battered child, possible liver injury
Laparotomy
Location of Hematoma
Associated Injuries
2nd, 3rd, and 4th portions of duodenum 2nd, 3rd, and 4th Perforation of portions of 4th portion duodenum of duoas well as denum proximal jejunum 2nd portion of Transection of duodenum jejunum
Definitive Therapy
Follow-Up+
Nasogastric suction 6 days
2 weeks, asymptomatic
Duodenojejunostomy, gastrostomy, gastric suction 9 days+
6 years, asymptomatic (patient adopted)
2 months, asymptomatic
1 year, no physical abnormalities. Parents being treated in Child Abuse Clinic 3 months, patient normal
Upper gastrointestinal study Upper gastrointestinal study
2nd portion of duodenum 2nd portion of duodenum
Jejunojejunostomy and nasogastric suction 9 days Nasogastric suction 3 days Nasogastric suction 4 days
Upper gastrointestinal study
3rd portion of duodenum
Nasogastric suction 10 days
3rd and 4th Jejunal perforation portions of duodenum 2nd, 3rd, and 4th oortions of
Closure of perforation, nasogastric suction 8 days Nasogastric suction 9 days
7’
Perforative appendicitis
Laparotomy
8
Duodenal obstruction due to duodenal .nematoma .
Upper gastrointestinal study
Associated with bowel perforation. + All patients are presently alive. t This patient had the only complication-wound
No follow-up after discharge from hospital 1 month, asymptomatic
1 month, asymptomatic
l
infection and a ventral hernia requiring secondary repair.
bowel perforation were successfully treated by nasogastric suction and appropriate intravenous fluids. The minimum duration of suction was three days and the maximum ten days. (Table IV.) In our earlier series, five of the seven patients were treated by surgical evacuation of the hematoma. The patients who had associated bowel perforation underwent surgical closure of the perforation but had no specific surgical maneuver for the duodenal hematoma. Results. All of the patients survived and were discharged from the hospital on full oral intake. Those patients who were operated on for bowel perforation required varying periods of nasogastric suction postoperatively, during which time the duodenal hematoma was resorbed. (Table IV.) Comments
Traditionally, the recommended treatment for intramural duodenal hematoma has been surgical [3-5,10,11,15-171. The most common operation has been simple evacuation of the hematoma; however, gastroenterostomy as well as duodenal resection has been performed. Izant and Drucker [18] in 1964 suggested that the majority of infants and children
12
with intramural duodenal hematoma could be successfully treated without surgical intervention. This recommendation was made even though three of their four reported patients had been treated surgically. Holgerson and Bishop [B] in 1977 reported on nine patients with intramural duodenal hematoma, only one of whom was operated on. It is now becoming increasingly evident that when the surgeon can be reassured that there is no bowel perforation, the majority if not all of the infants and children with intramural duodenal hematoma will respond to nasogastric suction and appropriate intravenous fluids. This has been true of the last five patients treated in our institution and reported on herein. The number of patients who develop intramural duodenal hematoma as a result of child abuse is undoubtedly greater than has been previously suspected. In the present series, at least half the patients were clearly battered, and perhaps five of the eight were actually injured by an abusive adult. Since repeated child abuse frequently results in the death of the child and since all states now have laws requiring that abusive adults be reported, it is incumbent upon the surgeon to recognize child abuse both for the welfare of the child as well as for his own compliance with the existing laws of the land [I]. Each infant or
The American Journal of Surgery
Duodenal Hematoma
child who presents with duodenal be carefully
evaluated
hematoma
should
for the possibility
of child
abuse. Conclusions Intramural nized
duodenal
as the result
creasing
frequency.
perforation,
child
is being abuse
If there is no associated
it can be treated
and intravenous intervention
hematoma
of active
by nasogastric
recog-
with inbowel suction
fluids and does not require surgical
in the majority
of patients.
References 1. Child Abuse and Neglect: The problem and its management, vol 1. US Department of Health, Education and Welfare, Children’s Bureau/National Center on Child Abuse and Neglect, 1976. ?. An evaluation of the effectiveness of unit 14 of the “We Can Help” curriculum for health professionals, final report, p 2. Professional Continuing Education Demonstration Project on Child Abuse and Neglect. American Academy of Pediatrics, Department of Educational Affairs, 1977. 3. Devroede GJ, Tirol FT, Lo Russo VA, Narducci AE: Intramural hematoma of the duodenum and jejunum. Am J Surg 112: 947, 1966. 4. Judd OR, Taybi H, King H: intramural hematoma of the small bowel. Arch Surg 89: 527, 1964. 5. Spencer R, Bateman JD, Horn PL: Intramural hematoma of the intestine; a rare cause of intestinal obstruction. Surgery 41: 794, 1957. 6. Freeark, RJ, Corley RD, Norcross WJ, et al: Intramural hematoma of the duodenum. Arch Surg 92: 463, 1966. 7. Bailey WC, Akers DR: Traumatic intramural hematoma of the duodenum in children. A report of five cases. Am J Surg 110: 695, 1965. 8. Holgerson LO, Bishop HC: Nonoperative treatment of duodenal hematomata. J fediatr Surg 12: 11, 1976. 9. Mahour GH, Woolley MM, Gans SL, et al: Duodenal hematoma in infancy and childhood. J F’ediatr Surg 6: 153, 1971. 10. Golding MR. de Jong P, Parker JW: Intramural hematoma of the duodenum. Ann Surg 157: 573, 1963. 11. Janson KL, Stockinger F: Duodenal hematoma. Critical analysis of recent treatment technics. Am J Surg 129: 304, 1975. 12. Williams RD, Sargent FT: The mechanism of intestinal injury in trauma. J Trauma 3: 288, 1963. 13. Stewart DR, Byrd CL, Schuster SR: Intramural hematomas of the alimentary tract in children. Surgery 68: 550, 1970. 14. Felson B, Levin EJ: Intramural hematoma of the duodenum. A diagnostic roentgen sign. Radiology 63: 823, 1954. 15. Tank ES, Eraklis AJ, Gross RE: Blunt abdominal trauma in infancy and childhood. J Trauma 8: 439, 1969. 16. Magladry GW Jr, Mathewson C Jr: Duodenal obstruction due to trauma. Stanford Med Bull 1954. 17. Parrish RA, Edmondson HT. Moretz WH: Duodenal and biliary obstruction secondary to intramural hematoma. Am J Surg 108: 428, 1964. 18. lzant RJ, Drucker WR: Duodenal obstruction due to intramural hematoma in children. J Trauma 4: 797, 1964.
Discussion Carleton Mathewson, Jr (San Francisco, CA): Duodenal hematoma is a relatively rare manifestation of abdominal trauma which for some reason seems to occur most f’requently in children. Our first case reported in 1954 was
Volume 136, July 1976
a child aged nine years. The four subsequent cases reported in 1966 were all children, aged two, three, four, and seven years. Since that time, however, my experience has been confined mainly to adults, the last being an eighteen year old man who fell from his horse while roping a steer which subsequently trampled on his epigastrium. Freeark [6] in 1966 reported nine cases, all adults except one. It is noteworthy that in two of the five children reported on before this society in 1966, child abuse was the apparent cause of the duodenal injury, and may also have been a factor in a twenty-two month old female with multiple contusions of the face and body and no history of trauma. Because of its high retroperitoneal position, the duodenum is ordinarily not subject to trauma; however, it is fixed in a position overlying the vetebrae and therefore, like the pancreas, is particularly subject to certain types of blunt trauma. A flat, jarring blow to the abdomen is most apt to cause tearing of the small bowel or mesentery at a fixed point, such as the ligament of Treitz, whereas a sharp blow is apt to impinge the fixed duodenum against the vertebrae behind, causing, in effect, a crushing injury and resulting in damage to blood vessels with leakage of blood into the subserosal, intramuscular, or submucosal layers. As the blood accumulates, partial or complete obstruction results from compression of the mucosal layers. Hematomas of appreciable size may extend distally to the jejunum, where perforation of the serosa into the free peritoneal cavity may occur, or proximally into the second portion of the duodenum, causing impingement upon the biliary or pancreatic ducts. Because of the proximity of the pancreas, concurrent injury to this organ often occurs. Concomitant injury to contiguous organs will produce a clinical picture out of keeping with this entity. The authors have suggested that most, if not all, infants and children with intramural hematoma will respond to nasogastric suction and intravenous fluids. I agree that conservative management is worth a trial, provided the duodenal obstruction is not complicated, as evidenced by clinical signs of perforation or injury to contiguous organs. Associated injuries, if overlooked and neglected, may lead to serious complications, while surgical evacuation of the hematoma, if accomplished early, is most effective and reassuring. Recently an adult patient was subjected to laparotomy two days after blunt trauma to the abdomen because of vomiting and signs of an acute abdomen. At surgery a large intramural hematoma of the duodenum with an extensive retroperitoneal hematoma was encountered. It was elected to close the abdomen and place the patient on intravenous alimentation. Three weeks later complete duodenal obstruction was still present. He underwent reoperation and was found to have an organized hematoma with extensive scarring of the duodenal wall, requiring a bypass procedure for correction. Simple evacuation of the hematoma as an initial procedure would have prevented weeks of hospitalization and the subsequent surgery. I would suggest that if conservative therapy is not effective within a reasonable length of time, surgical inter-
13
Woolley, Mahour, and Sloan
vention be undertaken before complete organization of the hematoma has ensued. Jerrold K. Longerbeam (Riverside, CA): We have treated several patients, both children and adults, with intramural duodenal hematoma. One patient was a five year old battered child who, unknown to anyone, also had a coagulation disorder. Because the hematoma did not resolve with conservative therapy, he was operated on, and the hematoma was evacuated. The operation was not accompanied by any excessive blood loss, but almost immediately after operation, the patient began to bleed from the wound edges into the peritoneal cavity. Reexploration of the abdomen revealed bleeding from all incised surfaces. Therefore, mechanical control of the bleeding was not possible. The patient was treated with fresh whole blood, fresh frozen plasma, and factor VIII concentrates, but to no avail. He continued to bleed and eventually died. Coagulation studies, which were not done until after the bleeding started, revealed deficiencies in several clotting factors. In view of this tragic experience, I recommend that a coagulation profile be obtained in all patients with intramural duodenal hematomas, and especially in those patients who must have operative evacuation of the hematoma because of a failure of conservative therapy. Eric W. Fonkalsrud (Los Angeles, CA): As the authors have indicated, blunt trauma to the abdomen, particularly due to child abuse, is an increasingly common problem in the United States, and we should be aware of the frequent association of duodenal hematoma. Blunt trauma to the abdomen in a child frequently causes multiple injuries, one of the most common of which is splenic fracture. When exploring an abdomen for ruptured spleen, regardless of whether it is removed or repaired, would you repair a duodenal hematoma if it is found during the exploration? As Dr. Mathewson indicated, if one delays operation for a lengthy period while using nasogastric suction, a stricture will occasionally develop. We have had two such patients in our hospital, and suggest that after a period of four to five days of suction, if the lesion does not show signs of improvement, perhaps simple drainage of the hematoma by incision of the serosa may be the simplest method of management and result in a short hospitalization. How often do you do follow-up gastrointestinal series, and what other types of studies do you recommend for follow-up of these patients after the hematoma is identified? Lastly, not only does the hematoma dissect distally down the jejunum, but it may also progress proximally. One of our patients had almost complete obstruction of the ampulla, which later strictured, causing further obstruction to both the pancreatic and bile ducts. Morton M. Woolley (closing): In response to Dr. Mathewson, although the majority of patients with intramural duodenal hematoma do not require surgery, there are a few patients whose hematomas do not resolve in a reasonable period of time, and these patients should be operated on. Since I care only for infants and children, there may be a
14
significant difference in the response of adults. This can be determined only by prospective clinical observation. Most important is the recognition of the lesion along with the awareness that there may be other associated injuries which might require surgical therapy. If an accurate diagnosis can be established, then one has the reassurance that early surgical therapy is not necessary for intramural duodenal hematoma and that in the majority of instances the lesion will respond to nonsurgical therapy. Dr. Longerbeam’s case is very interesting. The majority of patients with congenital coagulopathy have a history of previous bleeding episodes, and I am at a loss to explain this patient’s catastrophic coagulopathy. Perhaps the reason for the patient’s nonresponse to nasogastric suction was the coagulopathy which may have propagated the hematoma, in contrast to the patient with normal coagulation in whom the hematoma tends to resorb. The fact that this patient was recognized as having been battered simply adds to our fund of suspicion of this being the etiologic factor in each patient with intramural duodenal hematoma. Dr. Fonkalsrud introduced an interesting theoretical problem. We have not seen ruptured spleen in combination with intramural duodenal hematoma. If the two do occur in the same patient, we would not operate on the patient if the bleeding from the ruptured spleen has spontaneously abated. If there is continued bleeding from the splenic injury, following Dr. Morganstern’s lead, we are suturing lacerations rather than removing the spleen. If there happened to be a hematoma of the duodenum in association with the splenic injury, I would not drain it because of our satisfactory experience without drainage. Incidentally, drainage of a duodenal hematoma does not necessarily preclude the eventual development of stricture. There is at least one case reported in the literature in which a stricture developed subsequent to surgical drainage. How do we follow them? After the diagnosis has been established by an upper gastrointestinal study, the patients are followed by the daily volume and characteristics of the nasogastric suction. If the drainage remains voluminous and green, the patient is obstructed. When the obstruction abates, the volume decreases and the green color of fluid abates. In the past we have arbitrarily decided that a patient who is obstructed for ten days will be operated on. I had one patient who was scheduled for surgery on the tenth day; however, the evening before, the nasogastric return decreased precipitously and the operation was cancelled. With available intravenous nutrition, perhaps the surgical intervention could be delayed, but that would be a matter of judgment in each case. Obstruction of the ampulla of Vater causing pancreatitis is an interesting concept, and I appreciate Dr. Fonkalsrud’s allusion to a patient that he cared for. It is inviting to assume that the pancreatitis is due to obstruction of the ampulla of Vater secondary to the intramural hematoma. However, we had no documentation of associated common duct obstruction; therefore, we assume that the associated pancreatitis was due to direct trauma to the pancreas rather than obstruction to the ampulla of Vater.
The American Journal of Surgery
Duodenal Hematoma in Infancy and Childhood Changing Etiology and Changing Treatment Morton M. Woolley, MD, Los Angeles, California G. Hossein Mahour, MD, Los Angeles, California
Timothy Sloan, MD, Los Angeles, California
It is estimated that between 2300,000 and 4,000,OOO cases of active child abuse occur in the United States annually [I], and estimated deaths due to child abuse vary from 2,000 [2] to 50,000 annually [I]. The extreme variation in estimates is due to the difficulties inherent in proving or disproving child abuse. The child is either too young to testify on his own behalf or too frightened to do so. The abusive adult is not apt to admit to the abusive act, and those who live with him or her will assume a protective posture toward the abuser, thus denying all such allegations. Although the number of reported cases of intramural duodenal hematoma is increasing, there has been no consistent reportage of the association of active child abuse with this injury. Some of the case reports indicate “trauma of unknown etiology.” Such injuries may, in retrospect, be due to child abuse [3-81. In 1969 we reported our experience with seven patients who were treated for intramural duodenal hematoma [9]. Traumatic injury was denied by the parents of one patient, and in another the details of the trauma were not available. In retrospect, these two patients may have been injured by an abusive adult; however, at the time the manuscript was completed none of the patients was recognized as having been actively abused. During the subsequent seven years (1969-1977) eight patients have been treated for duodenal hematoma at the Childrens Hospital of Los Angeles. A retrospective review of these patients forms the basis of the present report. From the Department of Surgery, Childrens Hospital of Los Angeles, and the University of Southern California School of Medicine, Los Angeles, California. Reprint requests should be addressed to Morton M. Woolley, MD. Department of Surgery, Childrens Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, California 90054. Presented at the Forty-Ninth Annual Meeting of the Pacific Coast Surgical Association, Newport Beach, California, February 19-22, 1976.
8
Etiology of Intramural Duodenal Hematoma
Although there are isolated case reports of patients developing duodenal hematoma secondary to blood dyscrasia [3,5,10] or during anticoagulant therapy [II], the majority of patients in all age groups, and practically all of the patients in the infancy and childhood groups, develop intramural duodenal hematoma secondary to blunt abdominal trauma. Williams and Sargent [12] have demonstrated that traumatic intestinal injury is the result of the bowel being crushed between the anterior abdominal wall and the vertebral column rather than by a rapid compression-decompression injury. The duodenum,
gastroduodenal
sup.pancreaticduodenal a.
inf.pancreaticduodenal a. Sup. mesfsteric
a.
Figure 1. The duodenum is relatively fixed close to the vertebral bodies and has a copious blood supply from the superior and inferior pancreatlcoduodenal arteries.
The American Journal of Surgery
Duodenal Hematoma
being relatively fixed, is prone to injury if enough force is applied to the anterior abdominal wall when the muscles are either relaxed or too weak to resist the force of the significant blow. (Figures 1 and 2.) Since the duodenum has a copious blood supply, the injury may cause rupture of blood vessels, resulting in extravasation of blood between the mucosa and serosa. The hematoma then collects additional fluid and gradually compresses the mucosa against the opposite side of the duodenum producing varying degrees of luminal obstruction. (Figure 3.) In the present series, a history of trauma was obtained in all cases. (Table I.) In four of the eight patients, the trauma was due to child battering. In one additional case (case 4) child abuse was suspected because physical examination revealed multiple bruises; however, abuse was not proved beyond doubt. Clinical Course of Patients Historical Information and Symptoms. One of the ubiquitous characteristics of child abuse is a history that is either overtly misleading or covertly in-
consistent. The family structure is frequently unstable, as in the four battered children in the present series. In two, the child had been battered by the mother’s boyfriend. (Table I.) In one instance, the patient was brought to the hospital five days after the alleged injury. Part of the delay may have been due to delayed onset of vomiting, which is characteristic of intramural duodenal hematoma. In addition, parents of battered children frequently procrastinate in seeking medical care for fear of reprisal. If one suspects a traumatic injury as a result of child abuse, the historical factors must be given little, if any, credence. Physical Findings. Tenderness is usually present in the upper abdomen. (Table II.) A well defined abdominal mass is the exception rather than the rule, but occasionally one will perceive a right upper quadrant mass with ill defined borders if the hematoma is of adequate size to be palpated [13]. If there is bowel perforation in association with the hematoma, the predominant findings will be those of peritonitis. (Table II.) Laboratory Findings. The quantity of blood lost into the intramural hematoma may be significant. In five of the eight patients reported on herein, there was a decrease in the level of hemoglobin of 3 gm/lOO
01 Th12
Figure 2.
Blunt force applied to the anterior abdominal wall may result in rupture of the intramural blood vessels lf the force Is not great enough to perforate the bowel.
Volume 136, July 1878
Figure 3. Rupture of the blood vessels resdts in dissection of the tissues wtthin the wall of the duodenum. The mucosa is apposed to the opposite wall of the duodenum, thus resuttlng in varying degrees of obstruction.
Woolley,
TABLE I
Mahour,
Demographic Data on 8 Patients with Duodenal Hematoma
Case
l
Sex/Age
Family Structure
Caucasian
2’
M/2.5
Black
3’ 4
M/1.7 M11.9
Spanish American Spanish American
5 6
M/5 F/2.6
Spanish American Spanish American
7’
Ml4
Caucasian
8
M15.3
Type of Trauma
Parents married, living together, patient adopted at 5 days of age Parents divorced, mother has custody Parents married, living together Natural father in Mexico, patient lives with mother and stepfather Parents married, living together Mother married, but not to patient’s father Parents divorced, mother living with boyfriend Parents married, living together
Battered by parent
Battered by parent Fell against tricycle handlebar Fell from rocking horse (suspected battering but not proved) Fell from tree on doghouse Battered by mother’s boyfriend Battered by mother’s boyfriend Fell on bicycle handlebars
Associated with bowel perforation.
Historical and Phvsical Findings on 8 Patients with Duodenal Hematoma Symptoms
Interval between Trauma and Symptoms
Interval between Trauma and Admission
1
Vomiting
3 days
5 days
2’
Anorexia, abdominal pain, vomiting Vomiting, abdominal pain Vomiting
7
2 days (?)
2.5 days
5.5 days
Vomiting Vomiting, hematemesis Abdominal pain, vomiting Vomiting, abdominal pain
12hr 36 hr
2 days 2.5 days
3-4 hr
15hr
9 hr
24 hr
3’ 4
5 6 7’ 8
l-2
hr
32 hr
Physical Findings Dehydration, multiple bruises, abdominal tenderness, fear, irritability Dehydration, apathetic, generalized abdominal tenderness Lethargic, shock (blood pressure 70/50), abdomen silent and diffusely tender Lethargic, dehydrated, bruises on abdomen, right upper quadrant tenderness Generalized abdominal tenderness Pale, withdrawn, abdominal tenderness, many bruises Diffuse abdominal tenderness, distension, bruises, febrile, acutely ill Epigastric tenderness
Associated with bowel perforation.
TABLE III
Laboratory Data on 8 Patients with Duodenal Hematoma Hemoglobin (gm/lOO ml)
Case
10
Race
Ml.9
Case
l
(yr)
1
TABLE II
l
and Sloan
White Blood Cell Count
Serum Amylase
1 2’ 3’ 4 5 6
13.4 11.1 14.1 12.0 12.2 11.3
decreasing to 8.9 decreasing to 7.7 decreasing to 6.2 decreasing to 9.0 with no significant decrease decreasing to 6.3
26,500 6,600 4,200 14,800 16,200 10,100
390 59 149 62 905 1,695
7’ 8
13.8 with no significant decrease 12.0 to 11.0
5.900 11,200
124 136
Associated
Remarks 2 blood transfusions Blood transfusion to normal hemoglobin No blood given No blood given No blood given No transfusions given. Hemoglobin spontaneously increased to 10.4 at time of discharge No transfusions given No transfusions given
with bowel perforation
The American Journal of Surgery
Duodenal tiematoma
figure 4. Case 6. Roentgenogram revearing complete obstruction of the duodenum due to extensive intramural duodenal hematoma.
ml or more. (Table III.) The white blood cell count was elevated in those patients who had intramural duodenal hematoma but, for some unknown reason, was not elevated in those who had associated bowel perforation. (Table III.) The serum amylase level was elevated in three of the eight patients, indicative of associated traumatic pancreatitis. The patients with traumatic pancreatitis were limited to those without bowel perforation. Roentgenographic Findings. The roentgenographic findings of duodenal hematoma were first described by Felson and Levin [14] in 1954. If the hematoma has progressed to the point of complete obstruction, no contrast medium will pass through the duodenum. (Figure 4.) If the hematoma displaces the mucosa but does not completely obstruct the lumen, there will be evidence of an intramural filling defect which compresses the valvulae conniventes, resulting in a “coiled spring” appearance similar to that of intussusception. (Figure 5.) As the obstructive mechanism is alleviated by resorption of the hematoma, follow-up gastrointestinal studies will reveal eventual disappearance of the hematoma. (Figure 6.) ‘I’hese roentgenographic findings are now recognized to be diagnostic, so that one can depend on the upper gastrointestinal study for definitive diagnosis. Associated Injuries. In three of the eight patients reported on herein, there was perforation of the proximal jejunum or distal duodenum in association
Volume 136, July 1976
Figure 5. (Case 5. Upper gastroirztestinal study showing a filling defect as well as a coiled spring appearance of intramural dwodenaf hematoma.
Figure 6. Case 6. Upper gastrointestinal study two weeks after injwry showing resolution of intramural duodenal hematoma.
with intramural hematoma. (Table IV.) Perforation of the bowel may be either an index of the severity of the blow or perhaps be due to the anatomic location of the injury. The bowel perforations were all very close to the ligament of Treitz, where the duodenum is relatively fixed and close to the vertebral column. Bruises were observed on the children who had been abused. Therapy. The five patients who had an established diagnosis of duodenal hematoma without associated
11
Mahour, and Sloan
Woolley.
TABLE
IV
Clinical Diagnosis
Case 1
2’
3‘
4 5
6
Clinical Course and Follow-Up of 8 Patients with Duodenal Hematoma Diagnosis Defined by
Gastritis and bruising possibly due to blood dyscrasia Perforative appendicitis
Upper gastrointestinal study
Small bowel perforation, possible pancreatitis Duodenal hematoma
Laparotomy
Possible duodenal hematoma, possible traumatic pancreatitis Battered child, possible liver injury
Laparotomy
Location of Hematoma
Associated Injuries
2nd, 3rd, and 4th portions of duodenum 2nd, 3rd, and 4th Perforation of portions of 4th portion duodenum of duoas well as denum proximal jejunum 2nd portion of Transection of duodenum jejunum
Definitive Therapy
Follow-Up+
Nasogastric suction 6 days
2 weeks, asymptomatic
Duodenojejunostomy, gastrostomy, gastric suction 9 days+
6 years, asymptomatic (patient adopted)
2 months, asymptomatic
1 year, no physical abnormalities. Parents being treated in Child Abuse Clinic 3 months, patient normal
Upper gastrointestinal study Upper gastrointestinal study
2nd portion of duodenum 2nd portion of duodenum
Jejunojejunostomy and nasogastric suction 9 days Nasogastric suction 3 days Nasogastric suction 4 days
Upper gastrointestinal study
3rd portion of duodenum
Nasogastric suction 10 days
3rd and 4th Jejunal perforation portions of duodenum 2nd, 3rd, and 4th oortions of
Closure of perforation, nasogastric suction 8 days Nasogastric suction 9 days
7’
Perforative appendicitis
Laparotomy
8
Duodenal obstruction due to duodenal .nematoma .
Upper gastrointestinal study
Associated with bowel perforation. + All patients are presently alive. t This patient had the only complication-wound
No follow-up after discharge from hospital 1 month, asymptomatic
1 month, asymptomatic
l
infection and a ventral hernia requiring secondary repair.
bowel perforation were successfully treated by nasogastric suction and appropriate intravenous fluids. The minimum duration of suction was three days and the maximum ten days. (Table IV.) In our earlier series, five of the seven patients were treated by surgical evacuation of the hematoma. The patients who had associated bowel perforation underwent surgical closure of the perforation but had no specific surgical maneuver for the duodenal hematoma. Results. All of the patients survived and were discharged from the hospital on full oral intake. Those patients who were operated on for bowel perforation required varying periods of nasogastric suction postoperatively, during which time the duodenal hematoma was resorbed. (Table IV.) Comments
Traditionally, the recommended treatment for intramural duodenal hematoma has been surgical [3-5,10,11,15-171. The most common operation has been simple evacuation of the hematoma; however, gastroenterostomy as well as duodenal resection has been performed. Izant and Drucker [18] in 1964 suggested that the majority of infants and children
12
with intramural duodenal hematoma could be successfully treated without surgical intervention. This recommendation was made even though three of their four reported patients had been treated surgically. Holgerson and Bishop [B] in 1977 reported on nine patients with intramural duodenal hematoma, only one of whom was operated on. It is now becoming increasingly evident that when the surgeon can be reassured that there is no bowel perforation, the majority if not all of the infants and children with intramural duodenal hematoma will respond to nasogastric suction and appropriate intravenous fluids. This has been true of the last five patients treated in our institution and reported on herein. The number of patients who develop intramural duodenal hematoma as a result of child abuse is undoubtedly greater than has been previously suspected. In the present series, at least half the patients were clearly battered, and perhaps five of the eight were actually injured by an abusive adult. Since repeated child abuse frequently results in the death of the child and since all states now have laws requiring that abusive adults be reported, it is incumbent upon the surgeon to recognize child abuse both for the welfare of the child as well as for his own compliance with the existing laws of the land [I]. Each infant or
The American Journal of Surgery
Duodenal Hematoma
child who presents with duodenal be carefully
evaluated
hematoma
should
for the possibility
of child
abuse. Conclusions Intramural nized
duodenal
as the result
creasing
frequency.
perforation,
child
is being abuse
If there is no associated
it can be treated
and intravenous intervention
hematoma
of active
by nasogastric
recog-
with inbowel suction
fluids and does not require surgical
in the majority
of patients.
References 1. Child Abuse and Neglect: The problem and its management, vol 1. US Department of Health, Education and Welfare, Children’s Bureau/National Center on Child Abuse and Neglect, 1976. ?. An evaluation of the effectiveness of unit 14 of the “We Can Help” curriculum for health professionals, final report, p 2. Professional Continuing Education Demonstration Project on Child Abuse and Neglect. American Academy of Pediatrics, Department of Educational Affairs, 1977. 3. Devroede GJ, Tirol FT, Lo Russo VA, Narducci AE: Intramural hematoma of the duodenum and jejunum. Am J Surg 112: 947, 1966. 4. Judd OR, Taybi H, King H: intramural hematoma of the small bowel. Arch Surg 89: 527, 1964. 5. Spencer R, Bateman JD, Horn PL: Intramural hematoma of the intestine; a rare cause of intestinal obstruction. Surgery 41: 794, 1957. 6. Freeark, RJ, Corley RD, Norcross WJ, et al: Intramural hematoma of the duodenum. Arch Surg 92: 463, 1966. 7. Bailey WC, Akers DR: Traumatic intramural hematoma of the duodenum in children. A report of five cases. Am J Surg 110: 695, 1965. 8. Holgerson LO, Bishop HC: Nonoperative treatment of duodenal hematomata. J fediatr Surg 12: 11, 1976. 9. Mahour GH, Woolley MM, Gans SL, et al: Duodenal hematoma in infancy and childhood. J F’ediatr Surg 6: 153, 1971. 10. Golding MR. de Jong P, Parker JW: Intramural hematoma of the duodenum. Ann Surg 157: 573, 1963. 11. Janson KL, Stockinger F: Duodenal hematoma. Critical analysis of recent treatment technics. Am J Surg 129: 304, 1975. 12. Williams RD, Sargent FT: The mechanism of intestinal injury in trauma. J Trauma 3: 288, 1963. 13. Stewart DR, Byrd CL, Schuster SR: Intramural hematomas of the alimentary tract in children. Surgery 68: 550, 1970. 14. Felson B, Levin EJ: Intramural hematoma of the duodenum. A diagnostic roentgen sign. Radiology 63: 823, 1954. 15. Tank ES, Eraklis AJ, Gross RE: Blunt abdominal trauma in infancy and childhood. J Trauma 8: 439, 1969. 16. Magladry GW Jr, Mathewson C Jr: Duodenal obstruction due to trauma. Stanford Med Bull 1954. 17. Parrish RA, Edmondson HT. Moretz WH: Duodenal and biliary obstruction secondary to intramural hematoma. Am J Surg 108: 428, 1964. 18. lzant RJ, Drucker WR: Duodenal obstruction due to intramural hematoma in children. J Trauma 4: 797, 1964.
Discussion Carleton Mathewson, Jr (San Francisco, CA): Duodenal hematoma is a relatively rare manifestation of abdominal trauma which for some reason seems to occur most f’requently in children. Our first case reported in 1954 was
Volume 136, July 1976
a child aged nine years. The four subsequent cases reported in 1966 were all children, aged two, three, four, and seven years. Since that time, however, my experience has been confined mainly to adults, the last being an eighteen year old man who fell from his horse while roping a steer which subsequently trampled on his epigastrium. Freeark [6] in 1966 reported nine cases, all adults except one. It is noteworthy that in two of the five children reported on before this society in 1966, child abuse was the apparent cause of the duodenal injury, and may also have been a factor in a twenty-two month old female with multiple contusions of the face and body and no history of trauma. Because of its high retroperitoneal position, the duodenum is ordinarily not subject to trauma; however, it is fixed in a position overlying the vetebrae and therefore, like the pancreas, is particularly subject to certain types of blunt trauma. A flat, jarring blow to the abdomen is most apt to cause tearing of the small bowel or mesentery at a fixed point, such as the ligament of Treitz, whereas a sharp blow is apt to impinge the fixed duodenum against the vertebrae behind, causing, in effect, a crushing injury and resulting in damage to blood vessels with leakage of blood into the subserosal, intramuscular, or submucosal layers. As the blood accumulates, partial or complete obstruction results from compression of the mucosal layers. Hematomas of appreciable size may extend distally to the jejunum, where perforation of the serosa into the free peritoneal cavity may occur, or proximally into the second portion of the duodenum, causing impingement upon the biliary or pancreatic ducts. Because of the proximity of the pancreas, concurrent injury to this organ often occurs. Concomitant injury to contiguous organs will produce a clinical picture out of keeping with this entity. The authors have suggested that most, if not all, infants and children with intramural hematoma will respond to nasogastric suction and intravenous fluids. I agree that conservative management is worth a trial, provided the duodenal obstruction is not complicated, as evidenced by clinical signs of perforation or injury to contiguous organs. Associated injuries, if overlooked and neglected, may lead to serious complications, while surgical evacuation of the hematoma, if accomplished early, is most effective and reassuring. Recently an adult patient was subjected to laparotomy two days after blunt trauma to the abdomen because of vomiting and signs of an acute abdomen. At surgery a large intramural hematoma of the duodenum with an extensive retroperitoneal hematoma was encountered. It was elected to close the abdomen and place the patient on intravenous alimentation. Three weeks later complete duodenal obstruction was still present. He underwent reoperation and was found to have an organized hematoma with extensive scarring of the duodenal wall, requiring a bypass procedure for correction. Simple evacuation of the hematoma as an initial procedure would have prevented weeks of hospitalization and the subsequent surgery. I would suggest that if conservative therapy is not effective within a reasonable length of time, surgical inter-
13
Woolley, Mahour, and Sloan
vention be undertaken before complete organization of the hematoma has ensued. Jerrold K. Longerbeam (Riverside, CA): We have treated several patients, both children and adults, with intramural duodenal hematoma. One patient was a five year old battered child who, unknown to anyone, also had a coagulation disorder. Because the hematoma did not resolve with conservative therapy, he was operated on, and the hematoma was evacuated. The operation was not accompanied by any excessive blood loss, but almost immediately after operation, the patient began to bleed from the wound edges into the peritoneal cavity. Reexploration of the abdomen revealed bleeding from all incised surfaces. Therefore, mechanical control of the bleeding was not possible. The patient was treated with fresh whole blood, fresh frozen plasma, and factor VIII concentrates, but to no avail. He continued to bleed and eventually died. Coagulation studies, which were not done until after the bleeding started, revealed deficiencies in several clotting factors. In view of this tragic experience, I recommend that a coagulation profile be obtained in all patients with intramural duodenal hematomas, and especially in those patients who must have operative evacuation of the hematoma because of a failure of conservative therapy. Eric W. Fonkalsrud (Los Angeles, CA): As the authors have indicated, blunt trauma to the abdomen, particularly due to child abuse, is an increasingly common problem in the United States, and we should be aware of the frequent association of duodenal hematoma. Blunt trauma to the abdomen in a child frequently causes multiple injuries, one of the most common of which is splenic fracture. When exploring an abdomen for ruptured spleen, regardless of whether it is removed or repaired, would you repair a duodenal hematoma if it is found during the exploration? As Dr. Mathewson indicated, if one delays operation for a lengthy period while using nasogastric suction, a stricture will occasionally develop. We have had two such patients in our hospital, and suggest that after a period of four to five days of suction, if the lesion does not show signs of improvement, perhaps simple drainage of the hematoma by incision of the serosa may be the simplest method of management and result in a short hospitalization. How often do you do follow-up gastrointestinal series, and what other types of studies do you recommend for follow-up of these patients after the hematoma is identified? Lastly, not only does the hematoma dissect distally down the jejunum, but it may also progress proximally. One of our patients had almost complete obstruction of the ampulla, which later strictured, causing further obstruction to both the pancreatic and bile ducts. Morton M. Woolley (closing): In response to Dr. Mathewson, although the majority of patients with intramural duodenal hematoma do not require surgery, there are a few patients whose hematomas do not resolve in a reasonable period of time, and these patients should be operated on. Since I care only for infants and children, there may be a
14
significant difference in the response of adults. This can be determined only by prospective clinical observation. Most important is the recognition of the lesion along with the awareness that there may be other associated injuries which might require surgical therapy. If an accurate diagnosis can be established, then one has the reassurance that early surgical therapy is not necessary for intramural duodenal hematoma and that in the majority of instances the lesion will respond to nonsurgical therapy. Dr. Longerbeam’s case is very interesting. The majority of patients with congenital coagulopathy have a history of previous bleeding episodes, and I am at a loss to explain this patient’s catastrophic coagulopathy. Perhaps the reason for the patient’s nonresponse to nasogastric suction was the coagulopathy which may have propagated the hematoma, in contrast to the patient with normal coagulation in whom the hematoma tends to resorb. The fact that this patient was recognized as having been battered simply adds to our fund of suspicion of this being the etiologic factor in each patient with intramural duodenal hematoma. Dr. Fonkalsrud introduced an interesting theoretical problem. We have not seen ruptured spleen in combination with intramural duodenal hematoma. If the two do occur in the same patient, we would not operate on the patient if the bleeding from the ruptured spleen has spontaneously abated. If there is continued bleeding from the splenic injury, following Dr. Morganstern’s lead, we are suturing lacerations rather than removing the spleen. If there happened to be a hematoma of the duodenum in association with the splenic injury, I would not drain it because of our satisfactory experience without drainage. Incidentally, drainage of a duodenal hematoma does not necessarily preclude the eventual development of stricture. There is at least one case reported in the literature in which a stricture developed subsequent to surgical drainage. How do we follow them? After the diagnosis has been established by an upper gastrointestinal study, the patients are followed by the daily volume and characteristics of the nasogastric suction. If the drainage remains voluminous and green, the patient is obstructed. When the obstruction abates, the volume decreases and the green color of fluid abates. In the past we have arbitrarily decided that a patient who is obstructed for ten days will be operated on. I had one patient who was scheduled for surgery on the tenth day; however, the evening before, the nasogastric return decreased precipitously and the operation was cancelled. With available intravenous nutrition, perhaps the surgical intervention could be delayed, but that would be a matter of judgment in each case. Obstruction of the ampulla of Vater causing pancreatitis is an interesting concept, and I appreciate Dr. Fonkalsrud’s allusion to a patient that he cared for. It is inviting to assume that the pancreatitis is due to obstruction of the ampulla of Vater secondary to the intramural hematoma. However, we had no documentation of associated common duct obstruction; therefore, we assume that the associated pancreatitis was due to direct trauma to the pancreas rather than obstruction to the ampulla of Vater.
The American Journal of Surgery