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Hematoma of the duodenum
Hematoma REPORT
of the Duodenum
OF A SURGICALLY
PROVED
CASE
CAPT. BURTON GARFINKEL, KC., Ft. Jay, New York, MAX WALESON, M.D., Newark, New Jersey, AND NATHAN JAMES FURST, M.D., Newark, New Jersey
From tbe Departments of Radiology and Surgery, Newark Betb Israel Hospital, Newark, New Jersey.
EMATOMA of the duodenum as a cause of gastrointestina1 obstruction is a relatively infrequentIy reported entity. The case to be reported herein presents a typica pattern and is surgicaIIy proved.
H
CASE REPORT The patient was a four and a haIf year oId boy who was admitted to the hospita1 for persistent vomiting of two days’ duration associated with vague abdominal pain. At the time of admission the onIy history which appeared reIated to the present ilIness, as given by the parents who were reIiabIe medical observers (a doctor and nurse), was that two weeks prior to admission the patient had had “booster shots.” Since that time he had not been entireIy weI1, suffering from a croupy cough with expectoration of mucus. There had never been any previous simiIar episodes of vomiting. Except for variceIIa and occasional upper respiratory infections, the patient had aIways been well. There were no other positive findings in the past or famiIy histories. PhysicaI examination revealed a we11 developed, we11 nourished white maIe chiId of the stated age, in moderate distress and compIaining of vague abdomina1 pain. The patient appeared dehydrated and vomited frequentIy during the examination. The vomitus was bile stained. The patient’s temperature was 99%. and the puIse rate IOO per minute. The remaining positive physica findings were Iimited to the abdomen, which was diffuseIy tender and somewhat rigid with splinting. There was no rebound tenderness or distention. No masses were paIpabIe. A white bIood count on admission was 15,000 ceIIs per cu. mm., 80 per cent of which were poIymorphonucIear Ieukocytes with 4 per cent stab ceIIs. The urine; cohected whiIe the patient was AmericanJournal
of Surgery,
Volume 9s.
March.
1958
484
receiving a glucose infusion, showed z pIus gIucose and 4 plus acetone. A cIinica1 diagnosis of intestina1 obstruction was made and roentgenoIogica1 examinations were performed in an attempt to make a more definitive diagnosis. A survey fiIm of the abdomen showed the presence of an ovoid mass density, 5 cm. in diameter, in the left upper quadrant of the abdomen adjacent to the first two Iumbar vertebrae. This mass caused a pressure defect on the greater curvature of the stomach which was the onIy hohow viscus containing air. The psoas shadows were we11 defined. An intravenous pyeIogram (Fig. I) showed that this mass was not renaI in nature. With a barium swaIIow (Fig. z), the aforementioned defect on the greater curvature of the stomach was again demonstrated. The duodenal sweep showed irreguIarity, widening of the Iumen and a coarsening of the mucosa1 pattern. At no time did any barium proceed beyond the angIe of Treitz. A differentia1 diagnosis of mesenteric cyst, pancreatic cyst, retroperitonea1 tumor or hematoma was made. With the Iatter possibihty in mind, more pointed questioning of the patient and his parents reveaIed that tweIve days prior to admission the child had faIIen on a park bench and injured his abdomen. There had been no subsequent compIaints referabte to this trauma. Because of the persistent mass density and compIete obstruction at the IeveI of the retroperitonea1 duodenum surgery was performed forty-eight hours foIIowing admission. The patient was prepared with a nasogastric tube and the insertion of an intravenous poIyethyIene catheter. Under genera1 anesthesia a Ieft upper transrectus incision was made. A large hematoma was found in the area of the fourth portion of the duodenum extending into the Iigament of Treitz, dissecting subserosaIly aIong the first loop of jejunum and extending into the transverse mesocoIon anterior to the pancreas. There was compIete compression
Hematoma
of Duodenum
FIG. I. Demonstration of mass in left part of the abdomen, which was not related to the kidney but caused extrinsic pressure on stomach.
FIG. 2. Stomach and duodenum fiIIed with barium showing coarsened mucosat foIds of duodenum with obstruction after half an hour.
of the fourth portion of the (retroperitoneal) duodenum. The peritoneum over the mass was incised and al1 blood evacuated. ImmediateIy following this the normaI tone and coIor of the compressed and (proxima1) distended bowe1 returned. BIeeding points were secured and the peritoneum was reapproximated. The abdomen was closed in layers without drainage. The patient made an uneventfu1 recovery and had a good bowel movement on the fourth postoperative day. He was discharged on the seventh day after operation.
I. On the plain fiIm: A. A few distended Ioops in the Ieft upper quadrant B. An iI defined mass in the Iumen of a distended Ioop of smaI1 bowe1 in the Ieft upper quadrant C. ObIiteration or poor definition of the left psoas shadow I I. On gastrointestina1 examination : A. A space-occupying Iesion IO to 20 cm. in Iength involving the descending and transverse duodenum B. Thickening of the mucosa1 folds in the proxima1 portion of the abnorma1 segment C. Passage of the barium over the surface of a smooth, sharpIy marginated intramura1 mass which widens the Iumen of the duodenum D. Crowding of the vaIvuIae conniventes producing a coi1 spring appearance. (InfiItration of bIood or edema fluid into the mucosa occurs, thickening the vaIvuIae conniventes and producing the enIarged foIds seen radiographicaIIy. The cause of the coi1 spring pattern is not cIear) E. Evidence of extrinsic pressure on the greater curvature of the stomach and downward compression of the transverse coIon F. Obstruction
COMMENTS
Hematomas have been described in al1 areas of the gastrointestinal tract [2,4--lo]. They are most frequentIy associated with non-penetrating trauma to the abdomen. BIood dyscrasias are aIso known to be a predisposing factor [9]. There is a prediIection for hematomas to occur in the retroperitonea1 portion of the duodenum due to the reIative fixation of the gut at this point. Trauma causes this portion of the duodenum to be pressed against the spine suddenly, and the disruption of the mesenteric attachments in this area initiates hemorrhage [4]. The hematoma forms between the serosa and muscuIaris, and the resuIting mass causes obstruction [4]. This finding was evident in our case. FeIsen and Levin [4] consider the folIowing roentgenographic findings to be characteristic of hematoma of the duodenum: 485
GarfinkeI,
WaIeson
‘937. 2. DEY, D. L. Acute duodena1 obstruction due to an intramural haematoma. M. J. Australia, I : 708, 1952. 3. ESTES, W. abdomen.
hematoma of the duodenum-a diagnostic roentgen sign. Radiology, 63: 823-830, 1954. 5. JONES. G. E. and SETTLE. J. W.. JR. Obstructine Iesidn of the coIon due to non-penetrating traumi of the abdomen. Northwest Med., 5 I : 317-318,
‘952. 6. KRATZER, G. L. and DIXON, C. F. Traumatic submucosa1 hematoma of the mid-portion of the ascending coIon. Proc. Sta$ Meet., Mayo Clin., 26: 18-20, 1951. 7. LAMPERT, E. G. and GOODFELLOW,S. G. Traumatic subserosal hemorrhage causing smaI1 bowel obstruction. Ann. St&., 140: 768-770, 1954. 8. LIVERUD. K. Hematoma of the ieiunum. Acta. radial.; 30: 163-168, 1948. ’’ g. MELAMED, M. and PANTONE, A. M. Hematoma of the duodenum; a case report. Radiology, 66: 874-876. 1956. IO. OPPENHEIMER, G. D. Acute obstruction of the duodenum due to submucous haematoma. Ann. Surg., 98: 192-196, 1933.
A surgicaIIy documented case of hematoma of the duodenum is presented. The preoperative x-ray studies fuIfiIIed some of the diagnostic criteria reported in the Iiterature and reviewed in this report. to Dr. for per-
REFERENCES I. ALTHAUSEN,T. L., DEAMER, W. C. and KERR, W. J.
abdomen”;
Henoch’s
L. Nonpenetrating trauma of the Surg., Gynec. tY Obst., 74: 419-424,
‘942. 4. FELSON, B. and LEVIN, E. S. Intramural
SUMMARY
The fake “acute
Furst
and abdomina1 allergy. Ann. Surg., 106: 242-z5r,
In our case some, but not all, of the criteria were found. There was a mass in the Ieft upper quadrant of the abdomen, but air was seen only in the stomach and not in any distended Ioops of intestine. This, as we11 as the failure of the barium to pass over an intramura1 mass, was most IikeIy due to the fact that there was complete obstruction at the transverse duodenum. The duodena1 Iumen was widened, however, and the mucosa1 foIds were thickened.
Acknowledgment: We are gratefu1 Samuel Diener, Newark, New Jersey, mission to report this case.
and
purpura
486
of the Duodenum
OF A SURGICALLY
PROVED
CASE
CAPT. BURTON GARFINKEL, KC., Ft. Jay, New York, MAX WALESON, M.D., Newark, New Jersey, AND NATHAN JAMES FURST, M.D., Newark, New Jersey
From tbe Departments of Radiology and Surgery, Newark Betb Israel Hospital, Newark, New Jersey.
EMATOMA of the duodenum as a cause of gastrointestina1 obstruction is a relatively infrequentIy reported entity. The case to be reported herein presents a typica pattern and is surgicaIIy proved.
H
CASE REPORT The patient was a four and a haIf year oId boy who was admitted to the hospita1 for persistent vomiting of two days’ duration associated with vague abdominal pain. At the time of admission the onIy history which appeared reIated to the present ilIness, as given by the parents who were reIiabIe medical observers (a doctor and nurse), was that two weeks prior to admission the patient had had “booster shots.” Since that time he had not been entireIy weI1, suffering from a croupy cough with expectoration of mucus. There had never been any previous simiIar episodes of vomiting. Except for variceIIa and occasional upper respiratory infections, the patient had aIways been well. There were no other positive findings in the past or famiIy histories. PhysicaI examination revealed a we11 developed, we11 nourished white maIe chiId of the stated age, in moderate distress and compIaining of vague abdomina1 pain. The patient appeared dehydrated and vomited frequentIy during the examination. The vomitus was bile stained. The patient’s temperature was 99%. and the puIse rate IOO per minute. The remaining positive physica findings were Iimited to the abdomen, which was diffuseIy tender and somewhat rigid with splinting. There was no rebound tenderness or distention. No masses were paIpabIe. A white bIood count on admission was 15,000 ceIIs per cu. mm., 80 per cent of which were poIymorphonucIear Ieukocytes with 4 per cent stab ceIIs. The urine; cohected whiIe the patient was AmericanJournal
of Surgery,
Volume 9s.
March.
1958
484
receiving a glucose infusion, showed z pIus gIucose and 4 plus acetone. A cIinica1 diagnosis of intestina1 obstruction was made and roentgenoIogica1 examinations were performed in an attempt to make a more definitive diagnosis. A survey fiIm of the abdomen showed the presence of an ovoid mass density, 5 cm. in diameter, in the left upper quadrant of the abdomen adjacent to the first two Iumbar vertebrae. This mass caused a pressure defect on the greater curvature of the stomach which was the onIy hohow viscus containing air. The psoas shadows were we11 defined. An intravenous pyeIogram (Fig. I) showed that this mass was not renaI in nature. With a barium swaIIow (Fig. z), the aforementioned defect on the greater curvature of the stomach was again demonstrated. The duodenal sweep showed irreguIarity, widening of the Iumen and a coarsening of the mucosa1 pattern. At no time did any barium proceed beyond the angIe of Treitz. A differentia1 diagnosis of mesenteric cyst, pancreatic cyst, retroperitonea1 tumor or hematoma was made. With the Iatter possibihty in mind, more pointed questioning of the patient and his parents reveaIed that tweIve days prior to admission the child had faIIen on a park bench and injured his abdomen. There had been no subsequent compIaints referabte to this trauma. Because of the persistent mass density and compIete obstruction at the IeveI of the retroperitonea1 duodenum surgery was performed forty-eight hours foIIowing admission. The patient was prepared with a nasogastric tube and the insertion of an intravenous poIyethyIene catheter. Under genera1 anesthesia a Ieft upper transrectus incision was made. A large hematoma was found in the area of the fourth portion of the duodenum extending into the Iigament of Treitz, dissecting subserosaIly aIong the first loop of jejunum and extending into the transverse mesocoIon anterior to the pancreas. There was compIete compression
Hematoma
of Duodenum
FIG. I. Demonstration of mass in left part of the abdomen, which was not related to the kidney but caused extrinsic pressure on stomach.
FIG. 2. Stomach and duodenum fiIIed with barium showing coarsened mucosat foIds of duodenum with obstruction after half an hour.
of the fourth portion of the (retroperitoneal) duodenum. The peritoneum over the mass was incised and al1 blood evacuated. ImmediateIy following this the normaI tone and coIor of the compressed and (proxima1) distended bowe1 returned. BIeeding points were secured and the peritoneum was reapproximated. The abdomen was closed in layers without drainage. The patient made an uneventfu1 recovery and had a good bowel movement on the fourth postoperative day. He was discharged on the seventh day after operation.
I. On the plain fiIm: A. A few distended Ioops in the Ieft upper quadrant B. An iI defined mass in the Iumen of a distended Ioop of smaI1 bowe1 in the Ieft upper quadrant C. ObIiteration or poor definition of the left psoas shadow I I. On gastrointestina1 examination : A. A space-occupying Iesion IO to 20 cm. in Iength involving the descending and transverse duodenum B. Thickening of the mucosa1 folds in the proxima1 portion of the abnorma1 segment C. Passage of the barium over the surface of a smooth, sharpIy marginated intramura1 mass which widens the Iumen of the duodenum D. Crowding of the vaIvuIae conniventes producing a coi1 spring appearance. (InfiItration of bIood or edema fluid into the mucosa occurs, thickening the vaIvuIae conniventes and producing the enIarged foIds seen radiographicaIIy. The cause of the coi1 spring pattern is not cIear) E. Evidence of extrinsic pressure on the greater curvature of the stomach and downward compression of the transverse coIon F. Obstruction
COMMENTS
Hematomas have been described in al1 areas of the gastrointestinal tract [2,4--lo]. They are most frequentIy associated with non-penetrating trauma to the abdomen. BIood dyscrasias are aIso known to be a predisposing factor [9]. There is a prediIection for hematomas to occur in the retroperitonea1 portion of the duodenum due to the reIative fixation of the gut at this point. Trauma causes this portion of the duodenum to be pressed against the spine suddenly, and the disruption of the mesenteric attachments in this area initiates hemorrhage [4]. The hematoma forms between the serosa and muscuIaris, and the resuIting mass causes obstruction [4]. This finding was evident in our case. FeIsen and Levin [4] consider the folIowing roentgenographic findings to be characteristic of hematoma of the duodenum: 485
GarfinkeI,
WaIeson
‘937. 2. DEY, D. L. Acute duodena1 obstruction due to an intramural haematoma. M. J. Australia, I : 708, 1952. 3. ESTES, W. abdomen.
hematoma of the duodenum-a diagnostic roentgen sign. Radiology, 63: 823-830, 1954. 5. JONES. G. E. and SETTLE. J. W.. JR. Obstructine Iesidn of the coIon due to non-penetrating traumi of the abdomen. Northwest Med., 5 I : 317-318,
‘952. 6. KRATZER, G. L. and DIXON, C. F. Traumatic submucosa1 hematoma of the mid-portion of the ascending coIon. Proc. Sta$ Meet., Mayo Clin., 26: 18-20, 1951. 7. LAMPERT, E. G. and GOODFELLOW,S. G. Traumatic subserosal hemorrhage causing smaI1 bowel obstruction. Ann. St&., 140: 768-770, 1954. 8. LIVERUD. K. Hematoma of the ieiunum. Acta. radial.; 30: 163-168, 1948. ’’ g. MELAMED, M. and PANTONE, A. M. Hematoma of the duodenum; a case report. Radiology, 66: 874-876. 1956. IO. OPPENHEIMER, G. D. Acute obstruction of the duodenum due to submucous haematoma. Ann. Surg., 98: 192-196, 1933.
A surgicaIIy documented case of hematoma of the duodenum is presented. The preoperative x-ray studies fuIfiIIed some of the diagnostic criteria reported in the Iiterature and reviewed in this report. to Dr. for per-
REFERENCES I. ALTHAUSEN,T. L., DEAMER, W. C. and KERR, W. J.
abdomen”;
Henoch’s
L. Nonpenetrating trauma of the Surg., Gynec. tY Obst., 74: 419-424,
‘942. 4. FELSON, B. and LEVIN, E. S. Intramural
SUMMARY
The fake “acute
Furst
and abdomina1 allergy. Ann. Surg., 106: 242-z5r,
In our case some, but not all, of the criteria were found. There was a mass in the Ieft upper quadrant of the abdomen, but air was seen only in the stomach and not in any distended Ioops of intestine. This, as we11 as the failure of the barium to pass over an intramura1 mass, was most IikeIy due to the fact that there was complete obstruction at the transverse duodenum. The duodena1 Iumen was widened, however, and the mucosa1 foIds were thickened.
Acknowledgment: We are gratefu1 Samuel Diener, Newark, New Jersey, mission to report this case.
and
purpura
486