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Intramural hematoma of the duodenum and jejunum
Intramural
Hematoma
of the Duodenum
and Jejunum GHISLAIN J. DEVROEDE, M.D., Rochester, Minnesota, FRANCISCO T. TIROL, M.D., VIRGIL A. Lo Russo, M.D.,AND ANTHONY E. NARDUCCI, M.D.,Erie, Pennsylvania
From St. 1.inc-ent Hospital,
nal pains. Twelve hours before admission he had fallen on his abdomen across a monkey bar. Six hours later colicky upper abdominal pains developed and were accompanied by projectile vomiting. Two hours after this the pain became more continuous and localized at the periumbilical region. In the emergency room, it was noted that the boy had some tenderness and rigidity of the right upper part of the abdomen. Bowel sounds were hypoactive. Findings on a scan film of the abdomen showed no abnormality, and hematocrit value was 4:: per cent. The patient was admitted for observation. The following day the boy was asymptomatic and was discharged from the hospital. He was readmitted on the same evening, with severe pains and signs of obstruction of the upper intestinal tract. Hematocrit value had dropped to 30 per cent, but the leukocyte count remained within 8,000 cells per cu. mm. A hematoma of the right scrotal sac was noted on the third hospital day. Hematocrit value rose 3 per cent to 33 per cent, but the level of serum amylase increased to 1,200 units (the normal range is from 10 to 180 units). The boy became inactive, listless, and anorexic while the symptoms of obstruction persisted. Six days later a roentgenographic series of the upper gastromtestinal tract revealed a high grade obstruction of the distal region of the stomach and the superior and descending portions of the duodenum by what appeared to be an extrinsic mass (Fig. 1A.) The diagnoses of intramural hematoma of the duodenum and traumatic pancreatitis were considered. Results of laboratory examinations were negative for any bleeding tendencies Conservative management was carried out., and a second upper gastrointestinal series on the thirteenth hospital day showed that some improvement had taken place. (Fig. IB.) However, the boy’s clinical status gradually deteriorated, and exploratory laparotomv was performed nineteen days after admission. %th the abdomen relaxed under general anesthesia, a firm mass became palpable in the right hypochondriac region. On the lateral aspect of the
Erie, Pennsyluunia.
NTRAMURAL HEMATOMAS of the duodenum and the jejunum are rare lesions, but probably not as rare as the early literature indicates. Only fourteen cases had been reported by 1952. The first case was described after autopsy by Mclauchlan [1] in 1838. Meerwein was credited with effecting the first cure when in 1907 he resected a hematoma of the horizontal portion of the duodenum [Z]. In 194X Liverud [3] presented the first radiographic documentation of the condition, and in 1954 Felson and Levin [P] held as pathognomonic the radiographic demonstration of a “coiled spring” appearance. The paucity of cases of hematoma of the duodenum and jejunum reported in the early literature is, in the authors’ belief, due to failure to recognize this entity. This opinion is substantiated by the gradual increase of cases reported. In 1964 Judd, Taybi, and King [5] reviewed seventy-six cases, including those involving lesions of the ileum. Our survey of the literature disclosed ninety-seven documented eighty-three having appeared since reports, 1949. In addition we have seen three patients with intramural hematomas of the duodenum in a community hospital in recent months and believe that these are of sufficient interest to be reported along with the findings from the ninety-seven other cases reviewed. Two of the three hematomas in our patients were diagnosed preoperatively and proved surgically.
I
CASE REPORTS C.SE I. The patient, a six year old white boy, was admitted to the surgical service on the evening of January 24, 1964, complaining of episodic abdomiVol.112.Vecember 1966
947
Devroede,
Tirol,
Lo Russo,
and Narducci
FIG. 1. ITpper gastrointestinal series. A, (January 30. 1964) compression of lesser curvature of stomach producing displacement to left is noted. First and second portions of duodenum are markedly narrowed. B, (February 6, 1964) persistent narrowing is evident at junction of first and second portions of dutrdenum. C, (March 10, 1964) second portion of duodenum is moderatrly dilated. D, (July 6. 1964) there is marked scarrirlg of duodenum. descending portion of the duodenum. a dark blue, cvstic mass was seen which measured 3 inches in diameter and was sharply demarcated from the normal wall. Blood-tinged peritoneal fluid was noted. The gallbladder and common duct were distended. While the intestines were being packed away, the hematoma burst, exuding pinkish fluid. The mucosa bulged through the rent, while the gallbladder and common duct immediately lost their distention. The serosa and muscularis were dissected from the mucosa. The pancreas showed no evidence of damage. A drain was inserted near the duodenum and the abdomen was closed. Analysis of the cystic fluid revealed 90,000 units of amylase and 25.8 units
of lipase. The boy’s postoperative course was uneventful except for some fluctuation of the serum amvlase levels. On the thirty-ninth postoperati\ye da!:, results of laboratory tests revealed no abnormalities and the patient was discharged. On March 10 an upper gastrointestinal roentgenographic series showed some persistent duodenal dilatation. (Fig. 1C.) Another such examination (Fig. 1D) performed on July (i, 19&l demonstrated deformity of the duodenum, but the patient has not. to the present. exhibited any signs of obstruction. C:ISE II. The patient, a six year old white boy. was admitted to the hospital on February 2.5, I!Hi-l
Intramural Hematoma
$44:)
FIG. 2. A, plain film of abdomen taken October 20, 1901, showing marked gaseous distention of stomach B, upper gastrointestinal series performed on October 22, 1964 reveals constant deformity in duodc~ul bulb Second portion of duodenum after
being
is markedly struck
narrowed
by what appears to be an extrinsic
I)!- a car. IIe was brought
to the
emergency room in a somewhat lethargic but conscious condition. 13101~1ljressure was 60 mm. IHg systolic, and -iO mm. IIg diastolic. He complained of generalized abdominal pain and suffered from multiple lacerations and a fracture of the left femoral shaft. There was moderate generalized abdominal tenderness and rigidity. IJowcl sounds were hypoactive. A scan film of the abdomen showed considerable gaseous gastric dilatation. Kcsults of laboratory examinations were within normal limits, except for a leukocyte count of 13.000 cells per cu. mm. Exploration of the abdomen rtn the same day revealed a plum-sized, bluish cystic mass with sharply defined borders at the posterolateral aspect of the descending portion of the duodenum. There did not seem to be any encroachment on the lumen. Also noted was an extensive retroperitoneal hemorrhage on the right side, with no detectable source of active bleeding. The hematoma was evacuated and the abdomen closed without drainage. The postoperative course was uneventful, and the follow-up study unremarkable. CASE III. The patient, a three year old white boy, was admitted to the hospital on October 20, 1964 after he had fallen from a tree and hit his abdomen across the handlebar of a tricycle. Twenty-four hours later he became inactive and began to vomit just prior to arrival at the hospital. He had had a previous operation for intestinal obstruction due to a congenital band of the small intestine. Examination revealed the boy to have generalized ecchymotic patches and to be markedly pale and dehydrated. He had mild upper abdominal distention with
mass.
muscle guarding in his right upper abdomen. but no rigidity. KU mass was palpable. and bowel sour~ds were active. The vital signs were normal, and hematocrit was 32 per cent. Leukocyte count was 11.000 cells l’er cu. mm. which increased in two hours to 15,900 cells per cu. mm. Results of hcmorrhagic studies were noncontributorv. 1310~1 urea nitrogen was L’i mg. pet cent; carbon dioxide content, Ii.3 mEq.:’ L. ; chloride, 90 mEq.: L. ; sodium, 1% mEq. ‘L.; and potassium, 4.S mEq.+ L. Scan film of the abdomen re\-ealed a huge, gas-distended stomach and possible fluid in the peritoneal cavity. (Fig. ?A.) An upper gastrointestinal series performed two days later (Fig. ZB) revealed delayed duodenal filling, a constantly deformed duodenal bulb, and persistent narrowing of the descending portion b> what seemed to be an extrinsic mass. Intramural duodenal hematoma was d;agnosed, and the patient underwent surgery the next clay. Prior to operation a firm smooth tender mass, measuring 3 inches in diameter, was palpated at the upper outer margin of the right rectus muscle. It was better delineated when the abdomen was relaxed under general anesthesia. Blood-tinged, peritoneal fluid was present, and multiple blood-infiltrated regions were noted in the mesenterl;. The gallbladder and common bile duct were distended. Mobilization of the duodenum revealed a bluish mass within the wall of the descending portion. It extended to the horizontal and ascending portions of the duodenum and to the first 3 inches of the jejunum. Some parts of the mass were cystic, whereas others were firm. The lesion was smooth and had a very thin wall. b\‘hen the hematoma was incised, dark fluid oozed, but the rest of the clot had to be peeled away from the underlying
Devroede, Tirol, Lo Russo, and Narducci
950
TABLE I ETIOLOGICCLASSIFICATIONOF OF INTRAMURAL
HEMATOMA
ONE HUNDRED
CASES
OF DUODENUM
AND
bicycle, and so forth. (Table I.) More diffuse forces also have been cited, and trauma may be iatrogenic, resulting from injury occurring during surgery [1,3,6-ll ]. These hematomas also occur in those who have bleeding tendencies or who are receiving anticoagulant therapy. Such patients may have a “spontaneous” hematoma or hematoma precipitated by slight trauma. For lesions associated with pancreatic disease, two mechanisms may be responsible, namely, the digestion of an artery by an extending lesion or an acute inflammation of an aberrant pancreatic islet in the duodenal wall [5,12-153. A case was reported in which congenital duplication of the intestine was associated with an angioma [16], and several cases were reported as “spontaneous” hematomas. Cases of hematoma in alcoholic patients have been cited in the literature, although a history of trauma in such patients is difficult to elicit. In a patient reported by Wiot, Weinstein, and Felson [17] hematoma may have developed due to trauma sustained while the patient was lifting a heavy weight.
JE JUNUM
x0.
.igent
of
Cases
--. Trauma Kick to abdomen Fall on abdomen Crushing Unknown nature Surgical accident Fall on narrow object Coagulation defects
Diffuse force Diffuse force (?) Diffuse force (?) ? ? Local&cd force Spontaneous incidence (trauma?) Anticoagulants (trauma ?) Adenocarcinoma Acute pancreatitis Trauma (?) Spontaneous incidence (?) Unknown
Pancreatic disease
Alcoholism
Angioma and bowel reduplication Unknown
3
18 5 5 4 1 36 2
9
1 10
INCIDENCE Hematoma
muscularis. After this the gallbladder and common bile duct lost their distention. The serosa was closed with interrupted silk sutures, and the abdomen was closed routinely without drainage. Postoperative progress was gratifying, and the results of the upper gastrointestinal series on the sixth postoperative day revealed no abnormalities. The patient was discharged on the ninth postoperative day, and subseyuent follow-up studies were unremarkable. ETIOLOGIC
often
AND
of causes,
peculiar
SE.Y IN O.UE HUNDRED
cases
involving
may
to
4: 1 and,
in
trauma
were
trauma.
iejunal
at any
has been for
fixed
namely,
FEATVRES
occur
but
predilection
the
the
review
shows
that
of the duodenum
areas of loop,
proxitnal
and the terminal was
portion
noted
portion
the duodenal
angle,
jejunum, Our
male
as those not involving
tract
relatively
[18],
is more
of
II.)
Hematoma
the
ratio
is approximately
as frequent
intestinal
FEATURES
TO AGE
terms
trauma
The
PATHOLOGIC
TABLE OF CAUSE
patients
(Table
with
in children.
female twice
The most common cause of intramural hematoma of the duodenum and the jejunum is trauma. A comprehensive review of the literature directs attention to the sequelae of blunt trauma from narrow agents, such as the edge of a chair, a steering wheel, the handlebar of a
RELATIONSHIP
associated
seen
adjacent the
a to
intestine
the duodeno-
portion
region
of
the
of the ileum.
the descending involved
of the
to have
60 per
portion cent
of
II
PATIENTS
WITH
ISTRAMURAL
HEMATOMA
OF THE DUODENUM
AND JEJUNUM
r
Cause
Trauma
Other Total
O-20
2140
-Age
hr.1 41-60
M
F
M
F
47 4 51
9 4 13
12 5 17
1 0
2 5
1
‘7
M
61-80 F
2 1 3
M
u 6 6
Total F
M
F
0 2 2
61
12
20
American
81
7 19
Journal of Surgery
Intramural Hematoma the time; the horizontal portion, 55 per cent; the ascending portion, X3 per cent; and the superior portion, 2T per cent; and that the jejunum was involved 44 per cent of the time. Some patients had involvement of more than one region. Grossly. a collection of bluish intramural blood sharply demarcated from the normal segments is seen. Although the wall usually bursts easily on handling [3,6]. it may be adherent to the underlying organized clot as was seen the patient in our third case. Collection of blood in the peritoneum has been reported when there is a serosal rent and, more rarely, when blood ruptures into the lumen of the bowel. The blood may extravasate to the neighboring cellular tissue [Z], or it may travel along the insertion of the mesentery to the right inguinal canal. The latter seems to be the most obvious explanation for the scrotal hematoma of the patient reported in case I. Microscopic sections may show either subserosal or submucosal collections of blood or may show diffuse infiltration of all layers. The mucosa is always intact. Associated injuries also may be found. PATIIOGENESIS
Three mechanisms have been suggested in order to explain the injuries: (I) a bursting effect from sudden distention of a closed loop by forcible ejection of a dispersable material through the pylorus; (2) a crushing injury compressing the involved loop against the spinal column (it has been suggested that the strength of the force determines whether rupture or hematoma is produced although such an intramural hematoma was not able to be produced by experiments) [I%]; and (3) a tearing force. Spgngler [ISI] and Hiebel, Lang, and Fontaine [12] stressed the peculiar tangential insertion of the duodenojejunal mesentery, which makes that site a weak point. Separation of the leaves of the mescntery during distention of the bowel may rupture the blood vessels at their points of entrance. On reviewing the characteristics of the duodenum, one notes that the duodenum (1) is fixed and relatively closed at its junction with the pylorus and the ligament of Treitz; (2) has a relatively rigid mesentery ; (S) is the only portion of the intestinal tract with a double blood supply; (4) is made up of three layers of tissue having a varied gradient of elasticity, which are cemented together by loose connec-
9.51
tive tissue; (5) is a hollow closed loop which at any time may contain dispersable material ; and (G) is contained inside a cavity susceptible to sudden and forceful pressure changes. When these characteristics are considered, it can be seen that if, at any given time the duodenal loop is suddenly compressed by an adequate localizing force or by a sudden, increased intraabdominal pressure, the column of dispersable material contained in it will be forced along the luminary axis, seeking the point of least resistance. Encountering blockage at both extremities of the duodenum, this column will rebound into the loop effecting a sudden stretching and retracting of its walls. This mill subject the cementing connective tissue and the blood vessels to acute lines of force, producing tears. If the “stretch” effect is strong enough. it can rupture the wall. This mechanism also can occur with ease at the proximal portion of the jejunum and terminal part of the ileum and can explain the occurrence of the “spontaneous” hematomas in those patients with bleeding tendencies in whom the lesion could be produced by a fit of laughter, a coughing episode, straining, and so forth. SYMPTOiviS
AND
SIGNS
Hematomas of the superior, descending, and horizontal portions of the duodenum cause pain in the right region of the upper abdomen, whereas those of the duodenojejunal junction and the jejunum cause pain in the left upper abdominal quadrant or the whole abdomen. Projectile vomiting may contain bile, if the lesion is below the ampulla of Vater. These patients complain of constipation, but consistently pass flatus. On physical exarnination upper abdominal distention is generally noted. There may be muscle guarding but abdominal rigidity is absent, unless there is peritoneal irritation. Tenderness varies and its location depends on the site of the lesion. In our review of ninety-seven cases, we noted that a mass \vas felt in thirty-five of forty-six cases in which it was specifically sought. This mass may be palpable only during the acute phase of the disease. With the patient under general anesthesia, however, it becomes readily able to be delineated. It is movable and doughy and may even be visible as an abdominal bulging, its giving clue to the organ involved. location (Table III.) The gradual disappearance of the mass may signify successful conservative ther-
Devroede, Tirol, Lo Russo, and Narducci
952
TABLE SITE OF MASS OR PAIN
RELATIVE
TO LOCATION
OF LESION
III
IN ONE HUNDRED
CASES*
HEMATOMAOF THE
OF INTRAMURAL
DUODENUMAND JEJUNUM
Location of Lesion
Duodenum Jcjunum Total
------.1bdorninal Masst----Right Left Epigastric Upper Upper rlrea Quadrant Quadrant 19 1 20
2 6: 8
4 3 7
----i\bdominal Right Upper Quadrant 7 0 7
Pain----
Upper _1bdom-
Left Upper Quadrant
QuFTia!lt
I) 7 7
Periumbilical Area
Whole ;\bdomen
,
___~
~~
13 ci 19
2 5 7
9 1 10
* Data on mass or pain were incomplete in some cases t r\;o mass was palpated in eleven patients.
apy. On auscultation, a succussatory splash may be elicited in the upper portion of the abdomen and bowel soundsare hypoactive. Prolonged obstruction precipitates dehydration. Temperature elevation is noted only when there is blood resorption. The vital signs usually remain normal, except in a few cases in which shock is described. Courvoisier’s sign may be positive if there is obstruction to the bile flow [ZO]. In this situation, icterus may be apparent. Testicular pain has been attributed to duodenal rupture; in this case a right scrotal hematoma may be found. When trauma is the cause, an asymptomatic latent period has been noted, varying from a few minutes to twelve days, with an average of one to four clays. (Fig. 3.) This period is the interval required for the osmosis, bleeding, and edema to take place and the hematoma to develop. In patients with bleeding diathesis, there is grave illness and ominous manifestations. Because blood extravasation is generally present, signs of peritoneal reaction are noted. Finally, with pancreatic involvement, there will be specific findings.
LABORATORY
RADIOGRAPHIC
FEATURES
The plain film of the abdomen may reveal (1) gastric dilatation with gaseous distention to the site of lesion ; (2) external compression of the stomach; (9) a distended loop with an ill
6-10
FIG. 3. Length of asymptomatic latent period after trauma and before formation of intramural hematoma of duodenum and jejunum.
DATA
Hematocrit is decreased slightly, and the leukocyte count is elevated moderately. (Fig. 4.) In our review of ninety-seven collected cases, except for eight patients the leukocyte count was more than 10,000 cells per cu. mm., with a few counts as high as 20,000 per cu. mm. Serum amylase level may be elevated, with associated traumatic pancreatitis or obstruction of the duct of Wirsung. The icterus index rises, depending on the amount of mechanical interference to bile flow. Indirect bilirubin elevation due to blood resorption also may be detected [2,21]. A high hematocrit value, due to dehydration as well as dislocation of electrolytes, may be noted. Hemorrhagic studies reveal the bleeding diathesis, and the laboratory demonstration of pancreatitis is extremely reliable.
11-15
16-X
21-25
26-X
31-35
36-K
FIG. 4. Leukocyte count (given in thousands per cu. mm.) in one hundred cases of intramural hcmatoma of duodenum and jcjunurn.
Intramural defined mass [3,10]; (4) a crescent-shaped air shadow [5 1; or (5) fluid levels in the paralyzed loop. The upper gastrointestinal series is demonstrative. Liverud [3] described what Felson and Levin 14) termed the “coiled spring” sign, which represents an intramural extramucosal mass with crowding of the valvulae conniventes. An associated extrinsic defect of the greater curvature may be noted. Schoo’s case demonstrates that the “coiled spring” sign occurs only if intussusception of the dissected mucosa is present I7.91. In cases involving mucosal ulceration, barium collects in these pockets, causing most radiologists to prefer a water-soluble radiopayue medium. In cases involving bleeding diathesis, several physicians have described the “picket fence” appearance [WI, consisting of rigid, thickened mucosa with narrowing of the lumen and absence of the longitudinal folds. Mild extrinsic pressure and narrow spikes on the duodenal margin complete the picture. This is explained pathologically by a more diffuse infiltration of the wall by noncoagulable blood. The experimental picture reproduced by Felson and Levin [4] was similar to this description. An intravenous pyelogram may show a lateral displacement of the ureter, which could be taken as another clue pointing to the presence of this retroperitoneal lesion. DIFFERENTIAL
DIAGNOSIS
Intramural hematomas should be differentiated from other lesions. In intussusception, aside from a difference in the patient’s history, a shortening of the duodenum with a constricted lumen and without eccentricity is noted [4]. The “coiled spring” sign will be absent in these cases. An extramucosal neoplasm would have an insidious character and have no “coiled spring” sign, unless it is intussuscepted [17]. Kupture of organs usually is associated with a deteriorating clinical picture and typical changes as noted on laboratory findings. In our revie\v we noted that several patients were operated on for appendicitis, falsely suggested by the moderately elevated leukocyte count and the vague history. COURSE
.ZNI)
COMPLICATIONS
Sotne hematomas undergo spontaneous absorption, whereas others burst spontaneously into the peritoneal cavity. Several cases were
Hematoma
1-4.X3
reported in which fibrous organization of the clot occurred. This ranged from fibroblastic proliferation seen microscopically to stenosing obstruction [ZO] with small bands (221 as an intermediate. TREATMENT
The cause must be established prior tcl any treattnent since an operation may be disastrous in patients with bleeding tendencies [17]. In cases of trauma some authors believe that a ten day waiting period with conservative treatment should be tried prior to any surgery. In view of our experience and review of the literature and in consideration of the simplicity of the operation, we strongly believe that surgical intervention is the procedure of choice. Such treatment not only affords a definite evaluation of the lesions but also avoids prolonged morbidity. A Kocher maneuver is essential. For further visualization the ligament of Treitz may have to be transected. The usual treatment consists in the evacuation of the clot, with or without suturing of the serosa. We do not believe that a drain should be used since it may produce plication of the denuded mucosa, resulting in a diaphragmatic type of obstruction [7]. When the patency of the bowel is in doubt, a gastroenterostomy may be performed in conjunction with the evacuation of the blood clot. Some authors pass a Levin tube beyond the lesion to the jejunum, Resection of the affected bowel has been carried out in several instances when its viability was questionable [6]. The postoperative course generally is uneventful. Some patients, however, have recurrent obstruction, which could be due to incomplete evacuation of the blood clot or to recurrence of bleeding. SUMMARY
Three new cases reported herein and ninetyseven cases from the literature reveal that intramural hematomas of the duodenum and jejunum are not as rare as the early literature would indicate. These hematomas are characterized by upper gastrointestinal obstruction that occurs generally after trauma or they are associated with a bleeding tendency. A mass is frequently present. There is low grade leukocytosis. Radiographic studies often are pathognomonic. The hematoma may or may not be resorbed and may give rise to chronic obstruction. Treatment should consist of simple surgical evacuation of the clot without drainage. A
954 gastroenterostomy evacuation.
Devroede,
Tirol,
Lo Russo,
may be associated with the
Acknowledgment: Dr. James Jackman supplied the radiologic diagnosis on the first patient. REFERENCES 1, MCLAUCHLAN, J. Fatal false aneurysmal tumour occupying nearly the whole of the duodenum. Lance& 2: 203, 1838. 2. GUIBO, M. Contusions et ruptures traumatiques du duod&um. Real. gynbc. et chir. ahd., 15: 223, 349, 1910. 3. LIVERUD, K. Hematoma of the jejunum with subileus. Acta rudiol., 30: 163, 1948. 4. FELSON, B. and LEVIN, E. J. Intramural hematoma of the duodenum: diagnostic roentgen sign. Radiology, 63: 823, 1954. 5, JUDD, D. R., TAYRI, H., and KING, H. Intramural hematoma of the small bowel: a report of two cases and a review of the literature. birch. Surg., 89: 527, 1964. 6. MOORE, S. W. and ERLANDSON,M. E. Intramural hematoma of the duodenum. clnn. Surg., 157: 798, 1963. 7. ROWE, E. B., BAXTER, M. R., and ROLE, C. W. Intramural hematoma of the duodenum: report of a case with an unusual complication. Llrch. Surg., i8:560, 1959. 8. SENTURIA, H. R., SUSMAN, N., and SHYKEN, H. The roentgen appearance of spontaneous intramural hemorrhage of the small intestine associated with anticoagulant therapy. ..l-lm.J. Roentgenol., 86: 62, 1961. 9. SCHOO, B. H. Intramural hematoma causing intestinal obstruction. J. Kentucky M. .I., 61: 28, 1963. 10. SILBERT, B., FIGIEL, L. S., and FIGIEL, S. J. Intramural jejunal hematomas secondary to anticoagulant therapy. Anz. J. Digest Dis., 7:892, 1962.
and Narducci
11. SMITH, R. P. Intestinal obstruction due to submucosal hcmatoma of the jejunum in the newborn. J. Kansas hf. Sm., 40: 16, 1939. 12. HIEBEL, G., LANG, G., and FONTAINE. R. Tntraparietal duodenal hematomns: apropos of a case of spontaneous pancreatic origin. , Irrh. ma!. app. digest., 51: 1012, 1962. 13. JONES, G. E. and SETTLE, J. W., JR. Obstructing lesion of the colon due to non-penetrating trauma of the abdomen. Northwest Aled., 51: 317, 1952. 14. KERRY, R. L. and GLAS, W. W. Traumatic injuries to the pancreas and duodenum: a clinical and experimental study. _-Ivch. Surf., 85: 813, 1962. 15. KISSEL, P., RAUBERG, G.. DUREU~, J. B., SCHMITT, J., and MARCHAL, C. L. l_‘ne ktiologic rare de stenose duodenale: l’h&atome intrapariCta1 d’origine pancrbatique. .-Inn. m@d. Naanry, 3: 984, 1963. 16. WHITE, R. J. and WoLLE!ihIAN. 0. J. il case of intestinal obstruction from spontaneous subserosal hemorrhage with angiomatous malformation associated with reduplication of the jejunum. Ann. Sung., 143: 720, 1956. li. WIOT, J. F., WEINSTEIN, A. S., and FELSON, B. Duodenal hematoma induced by coumarin. Am. J. Roentgenol., 86: 70, 1961. 18. SPENCER, R., BATEMAS, J. D.. and HORN, P. L. Intramural hematoma of the intestine, a rare cause of intestinal obstruction: review of the literature and report of a case. Suvgrr_~, 41: 794, 1952. 19. SPANGLER, H. iiber subkutane Diimldarmrupturen. II-ien. med. Tl.chnschr., 108: 1014, 1958. 20. CULVER, G. J. and PIRSON, H. S. Intramural hcmatoma of the jejunum: a case report. ‘1%. J. Roentgenol., 90: 732, 1963. 21. FERGUSON, I. A., JR. and GOADE, W. J.. JR. Intramural hematoma of the duodenum: report of a case. Nez~ England J. Med., 260: 1176, 1959. 22. CULVER, G. J., PIRSON, H. S., MILCH, E., BERMAN, L., and ABRANTES, F. J, Intramural hematoma of the jejunum: a case report. Radiology, 76: 785, 1961.
Hematoma
of the Duodenum
and Jejunum GHISLAIN J. DEVROEDE, M.D., Rochester, Minnesota, FRANCISCO T. TIROL, M.D., VIRGIL A. Lo Russo, M.D.,AND ANTHONY E. NARDUCCI, M.D.,Erie, Pennsylvania
From St. 1.inc-ent Hospital,
nal pains. Twelve hours before admission he had fallen on his abdomen across a monkey bar. Six hours later colicky upper abdominal pains developed and were accompanied by projectile vomiting. Two hours after this the pain became more continuous and localized at the periumbilical region. In the emergency room, it was noted that the boy had some tenderness and rigidity of the right upper part of the abdomen. Bowel sounds were hypoactive. Findings on a scan film of the abdomen showed no abnormality, and hematocrit value was 4:: per cent. The patient was admitted for observation. The following day the boy was asymptomatic and was discharged from the hospital. He was readmitted on the same evening, with severe pains and signs of obstruction of the upper intestinal tract. Hematocrit value had dropped to 30 per cent, but the leukocyte count remained within 8,000 cells per cu. mm. A hematoma of the right scrotal sac was noted on the third hospital day. Hematocrit value rose 3 per cent to 33 per cent, but the level of serum amylase increased to 1,200 units (the normal range is from 10 to 180 units). The boy became inactive, listless, and anorexic while the symptoms of obstruction persisted. Six days later a roentgenographic series of the upper gastromtestinal tract revealed a high grade obstruction of the distal region of the stomach and the superior and descending portions of the duodenum by what appeared to be an extrinsic mass (Fig. 1A.) The diagnoses of intramural hematoma of the duodenum and traumatic pancreatitis were considered. Results of laboratory examinations were negative for any bleeding tendencies Conservative management was carried out., and a second upper gastrointestinal series on the thirteenth hospital day showed that some improvement had taken place. (Fig. IB.) However, the boy’s clinical status gradually deteriorated, and exploratory laparotomv was performed nineteen days after admission. %th the abdomen relaxed under general anesthesia, a firm mass became palpable in the right hypochondriac region. On the lateral aspect of the
Erie, Pennsyluunia.
NTRAMURAL HEMATOMAS of the duodenum and the jejunum are rare lesions, but probably not as rare as the early literature indicates. Only fourteen cases had been reported by 1952. The first case was described after autopsy by Mclauchlan [1] in 1838. Meerwein was credited with effecting the first cure when in 1907 he resected a hematoma of the horizontal portion of the duodenum [Z]. In 194X Liverud [3] presented the first radiographic documentation of the condition, and in 1954 Felson and Levin [P] held as pathognomonic the radiographic demonstration of a “coiled spring” appearance. The paucity of cases of hematoma of the duodenum and jejunum reported in the early literature is, in the authors’ belief, due to failure to recognize this entity. This opinion is substantiated by the gradual increase of cases reported. In 1964 Judd, Taybi, and King [5] reviewed seventy-six cases, including those involving lesions of the ileum. Our survey of the literature disclosed ninety-seven documented eighty-three having appeared since reports, 1949. In addition we have seen three patients with intramural hematomas of the duodenum in a community hospital in recent months and believe that these are of sufficient interest to be reported along with the findings from the ninety-seven other cases reviewed. Two of the three hematomas in our patients were diagnosed preoperatively and proved surgically.
I
CASE REPORTS C.SE I. The patient, a six year old white boy, was admitted to the surgical service on the evening of January 24, 1964, complaining of episodic abdomiVol.112.Vecember 1966
947
Devroede,
Tirol,
Lo Russo,
and Narducci
FIG. 1. ITpper gastrointestinal series. A, (January 30. 1964) compression of lesser curvature of stomach producing displacement to left is noted. First and second portions of duodenum are markedly narrowed. B, (February 6, 1964) persistent narrowing is evident at junction of first and second portions of dutrdenum. C, (March 10, 1964) second portion of duodenum is moderatrly dilated. D, (July 6. 1964) there is marked scarrirlg of duodenum. descending portion of the duodenum. a dark blue, cvstic mass was seen which measured 3 inches in diameter and was sharply demarcated from the normal wall. Blood-tinged peritoneal fluid was noted. The gallbladder and common duct were distended. While the intestines were being packed away, the hematoma burst, exuding pinkish fluid. The mucosa bulged through the rent, while the gallbladder and common duct immediately lost their distention. The serosa and muscularis were dissected from the mucosa. The pancreas showed no evidence of damage. A drain was inserted near the duodenum and the abdomen was closed. Analysis of the cystic fluid revealed 90,000 units of amylase and 25.8 units
of lipase. The boy’s postoperative course was uneventful except for some fluctuation of the serum amvlase levels. On the thirty-ninth postoperati\ye da!:, results of laboratory tests revealed no abnormalities and the patient was discharged. On March 10 an upper gastrointestinal roentgenographic series showed some persistent duodenal dilatation. (Fig. 1C.) Another such examination (Fig. 1D) performed on July (i, 19&l demonstrated deformity of the duodenum, but the patient has not. to the present. exhibited any signs of obstruction. C:ISE II. The patient, a six year old white boy. was admitted to the hospital on February 2.5, I!Hi-l
Intramural Hematoma
$44:)
FIG. 2. A, plain film of abdomen taken October 20, 1901, showing marked gaseous distention of stomach B, upper gastrointestinal series performed on October 22, 1964 reveals constant deformity in duodc~ul bulb Second portion of duodenum after
being
is markedly struck
narrowed
by what appears to be an extrinsic
I)!- a car. IIe was brought
to the
emergency room in a somewhat lethargic but conscious condition. 13101~1ljressure was 60 mm. IHg systolic, and -iO mm. IIg diastolic. He complained of generalized abdominal pain and suffered from multiple lacerations and a fracture of the left femoral shaft. There was moderate generalized abdominal tenderness and rigidity. IJowcl sounds were hypoactive. A scan film of the abdomen showed considerable gaseous gastric dilatation. Kcsults of laboratory examinations were within normal limits, except for a leukocyte count of 13.000 cells per cu. mm. Exploration of the abdomen rtn the same day revealed a plum-sized, bluish cystic mass with sharply defined borders at the posterolateral aspect of the descending portion of the duodenum. There did not seem to be any encroachment on the lumen. Also noted was an extensive retroperitoneal hemorrhage on the right side, with no detectable source of active bleeding. The hematoma was evacuated and the abdomen closed without drainage. The postoperative course was uneventful, and the follow-up study unremarkable. CASE III. The patient, a three year old white boy, was admitted to the hospital on October 20, 1964 after he had fallen from a tree and hit his abdomen across the handlebar of a tricycle. Twenty-four hours later he became inactive and began to vomit just prior to arrival at the hospital. He had had a previous operation for intestinal obstruction due to a congenital band of the small intestine. Examination revealed the boy to have generalized ecchymotic patches and to be markedly pale and dehydrated. He had mild upper abdominal distention with
mass.
muscle guarding in his right upper abdomen. but no rigidity. KU mass was palpable. and bowel sour~ds were active. The vital signs were normal, and hematocrit was 32 per cent. Leukocyte count was 11.000 cells l’er cu. mm. which increased in two hours to 15,900 cells per cu. mm. Results of hcmorrhagic studies were noncontributorv. 1310~1 urea nitrogen was L’i mg. pet cent; carbon dioxide content, Ii.3 mEq.:’ L. ; chloride, 90 mEq.: L. ; sodium, 1% mEq. ‘L.; and potassium, 4.S mEq.+ L. Scan film of the abdomen re\-ealed a huge, gas-distended stomach and possible fluid in the peritoneal cavity. (Fig. ?A.) An upper gastrointestinal series performed two days later (Fig. ZB) revealed delayed duodenal filling, a constantly deformed duodenal bulb, and persistent narrowing of the descending portion b> what seemed to be an extrinsic mass. Intramural duodenal hematoma was d;agnosed, and the patient underwent surgery the next clay. Prior to operation a firm smooth tender mass, measuring 3 inches in diameter, was palpated at the upper outer margin of the right rectus muscle. It was better delineated when the abdomen was relaxed under general anesthesia. Blood-tinged, peritoneal fluid was present, and multiple blood-infiltrated regions were noted in the mesenterl;. The gallbladder and common bile duct were distended. Mobilization of the duodenum revealed a bluish mass within the wall of the descending portion. It extended to the horizontal and ascending portions of the duodenum and to the first 3 inches of the jejunum. Some parts of the mass were cystic, whereas others were firm. The lesion was smooth and had a very thin wall. b\‘hen the hematoma was incised, dark fluid oozed, but the rest of the clot had to be peeled away from the underlying
Devroede, Tirol, Lo Russo, and Narducci
950
TABLE I ETIOLOGICCLASSIFICATIONOF OF INTRAMURAL
HEMATOMA
ONE HUNDRED
CASES
OF DUODENUM
AND
bicycle, and so forth. (Table I.) More diffuse forces also have been cited, and trauma may be iatrogenic, resulting from injury occurring during surgery [1,3,6-ll ]. These hematomas also occur in those who have bleeding tendencies or who are receiving anticoagulant therapy. Such patients may have a “spontaneous” hematoma or hematoma precipitated by slight trauma. For lesions associated with pancreatic disease, two mechanisms may be responsible, namely, the digestion of an artery by an extending lesion or an acute inflammation of an aberrant pancreatic islet in the duodenal wall [5,12-153. A case was reported in which congenital duplication of the intestine was associated with an angioma [16], and several cases were reported as “spontaneous” hematomas. Cases of hematoma in alcoholic patients have been cited in the literature, although a history of trauma in such patients is difficult to elicit. In a patient reported by Wiot, Weinstein, and Felson [17] hematoma may have developed due to trauma sustained while the patient was lifting a heavy weight.
JE JUNUM
x0.
.igent
of
Cases
--. Trauma Kick to abdomen Fall on abdomen Crushing Unknown nature Surgical accident Fall on narrow object Coagulation defects
Diffuse force Diffuse force (?) Diffuse force (?) ? ? Local&cd force Spontaneous incidence (trauma?) Anticoagulants (trauma ?) Adenocarcinoma Acute pancreatitis Trauma (?) Spontaneous incidence (?) Unknown
Pancreatic disease
Alcoholism
Angioma and bowel reduplication Unknown
3
18 5 5 4 1 36 2
9
1 10
INCIDENCE Hematoma
muscularis. After this the gallbladder and common bile duct lost their distention. The serosa was closed with interrupted silk sutures, and the abdomen was closed routinely without drainage. Postoperative progress was gratifying, and the results of the upper gastrointestinal series on the sixth postoperative day revealed no abnormalities. The patient was discharged on the ninth postoperative day, and subseyuent follow-up studies were unremarkable. ETIOLOGIC
often
AND
of causes,
peculiar
SE.Y IN O.UE HUNDRED
cases
involving
may
to
4: 1 and,
in
trauma
were
trauma.
iejunal
at any
has been for
fixed
namely,
FEATVRES
occur
but
predilection
the
the
review
shows
that
of the duodenum
areas of loop,
proxitnal
and the terminal was
portion
noted
portion
the duodenal
angle,
jejunum, Our
male
as those not involving
tract
relatively
[18],
is more
of
II.)
Hematoma
the
ratio
is approximately
as frequent
intestinal
FEATURES
TO AGE
terms
trauma
The
PATHOLOGIC
TABLE OF CAUSE
patients
(Table
with
in children.
female twice
The most common cause of intramural hematoma of the duodenum and the jejunum is trauma. A comprehensive review of the literature directs attention to the sequelae of blunt trauma from narrow agents, such as the edge of a chair, a steering wheel, the handlebar of a
RELATIONSHIP
associated
seen
adjacent the
a to
intestine
the duodeno-
portion
region
of
the
of the ileum.
the descending involved
of the
to have
60 per
portion cent
of
II
PATIENTS
WITH
ISTRAMURAL
HEMATOMA
OF THE DUODENUM
AND JEJUNUM
r
Cause
Trauma
Other Total
O-20
2140
-Age
hr.1 41-60
M
F
M
F
47 4 51
9 4 13
12 5 17
1 0
2 5
1
‘7
M
61-80 F
2 1 3
M
u 6 6
Total F
M
F
0 2 2
61
12
20
American
81
7 19
Journal of Surgery
Intramural Hematoma the time; the horizontal portion, 55 per cent; the ascending portion, X3 per cent; and the superior portion, 2T per cent; and that the jejunum was involved 44 per cent of the time. Some patients had involvement of more than one region. Grossly. a collection of bluish intramural blood sharply demarcated from the normal segments is seen. Although the wall usually bursts easily on handling [3,6]. it may be adherent to the underlying organized clot as was seen the patient in our third case. Collection of blood in the peritoneum has been reported when there is a serosal rent and, more rarely, when blood ruptures into the lumen of the bowel. The blood may extravasate to the neighboring cellular tissue [Z], or it may travel along the insertion of the mesentery to the right inguinal canal. The latter seems to be the most obvious explanation for the scrotal hematoma of the patient reported in case I. Microscopic sections may show either subserosal or submucosal collections of blood or may show diffuse infiltration of all layers. The mucosa is always intact. Associated injuries also may be found. PATIIOGENESIS
Three mechanisms have been suggested in order to explain the injuries: (I) a bursting effect from sudden distention of a closed loop by forcible ejection of a dispersable material through the pylorus; (2) a crushing injury compressing the involved loop against the spinal column (it has been suggested that the strength of the force determines whether rupture or hematoma is produced although such an intramural hematoma was not able to be produced by experiments) [I%]; and (3) a tearing force. Spgngler [ISI] and Hiebel, Lang, and Fontaine [12] stressed the peculiar tangential insertion of the duodenojejunal mesentery, which makes that site a weak point. Separation of the leaves of the mescntery during distention of the bowel may rupture the blood vessels at their points of entrance. On reviewing the characteristics of the duodenum, one notes that the duodenum (1) is fixed and relatively closed at its junction with the pylorus and the ligament of Treitz; (2) has a relatively rigid mesentery ; (S) is the only portion of the intestinal tract with a double blood supply; (4) is made up of three layers of tissue having a varied gradient of elasticity, which are cemented together by loose connec-
9.51
tive tissue; (5) is a hollow closed loop which at any time may contain dispersable material ; and (G) is contained inside a cavity susceptible to sudden and forceful pressure changes. When these characteristics are considered, it can be seen that if, at any given time the duodenal loop is suddenly compressed by an adequate localizing force or by a sudden, increased intraabdominal pressure, the column of dispersable material contained in it will be forced along the luminary axis, seeking the point of least resistance. Encountering blockage at both extremities of the duodenum, this column will rebound into the loop effecting a sudden stretching and retracting of its walls. This mill subject the cementing connective tissue and the blood vessels to acute lines of force, producing tears. If the “stretch” effect is strong enough. it can rupture the wall. This mechanism also can occur with ease at the proximal portion of the jejunum and terminal part of the ileum and can explain the occurrence of the “spontaneous” hematomas in those patients with bleeding tendencies in whom the lesion could be produced by a fit of laughter, a coughing episode, straining, and so forth. SYMPTOiviS
AND
SIGNS
Hematomas of the superior, descending, and horizontal portions of the duodenum cause pain in the right region of the upper abdomen, whereas those of the duodenojejunal junction and the jejunum cause pain in the left upper abdominal quadrant or the whole abdomen. Projectile vomiting may contain bile, if the lesion is below the ampulla of Vater. These patients complain of constipation, but consistently pass flatus. On physical exarnination upper abdominal distention is generally noted. There may be muscle guarding but abdominal rigidity is absent, unless there is peritoneal irritation. Tenderness varies and its location depends on the site of the lesion. In our review of ninety-seven cases, we noted that a mass \vas felt in thirty-five of forty-six cases in which it was specifically sought. This mass may be palpable only during the acute phase of the disease. With the patient under general anesthesia, however, it becomes readily able to be delineated. It is movable and doughy and may even be visible as an abdominal bulging, its giving clue to the organ involved. location (Table III.) The gradual disappearance of the mass may signify successful conservative ther-
Devroede, Tirol, Lo Russo, and Narducci
952
TABLE SITE OF MASS OR PAIN
RELATIVE
TO LOCATION
OF LESION
III
IN ONE HUNDRED
CASES*
HEMATOMAOF THE
OF INTRAMURAL
DUODENUMAND JEJUNUM
Location of Lesion
Duodenum Jcjunum Total
------.1bdorninal Masst----Right Left Epigastric Upper Upper rlrea Quadrant Quadrant 19 1 20
2 6: 8
4 3 7
----i\bdominal Right Upper Quadrant 7 0 7
Pain----
Upper _1bdom-
Left Upper Quadrant
QuFTia!lt
I) 7 7
Periumbilical Area
Whole ;\bdomen
,
___~
~~
13 ci 19
2 5 7
9 1 10
* Data on mass or pain were incomplete in some cases t r\;o mass was palpated in eleven patients.
apy. On auscultation, a succussatory splash may be elicited in the upper portion of the abdomen and bowel soundsare hypoactive. Prolonged obstruction precipitates dehydration. Temperature elevation is noted only when there is blood resorption. The vital signs usually remain normal, except in a few cases in which shock is described. Courvoisier’s sign may be positive if there is obstruction to the bile flow [ZO]. In this situation, icterus may be apparent. Testicular pain has been attributed to duodenal rupture; in this case a right scrotal hematoma may be found. When trauma is the cause, an asymptomatic latent period has been noted, varying from a few minutes to twelve days, with an average of one to four clays. (Fig. 3.) This period is the interval required for the osmosis, bleeding, and edema to take place and the hematoma to develop. In patients with bleeding diathesis, there is grave illness and ominous manifestations. Because blood extravasation is generally present, signs of peritoneal reaction are noted. Finally, with pancreatic involvement, there will be specific findings.
LABORATORY
RADIOGRAPHIC
FEATURES
The plain film of the abdomen may reveal (1) gastric dilatation with gaseous distention to the site of lesion ; (2) external compression of the stomach; (9) a distended loop with an ill
6-10
FIG. 3. Length of asymptomatic latent period after trauma and before formation of intramural hematoma of duodenum and jejunum.
DATA
Hematocrit is decreased slightly, and the leukocyte count is elevated moderately. (Fig. 4.) In our review of ninety-seven collected cases, except for eight patients the leukocyte count was more than 10,000 cells per cu. mm., with a few counts as high as 20,000 per cu. mm. Serum amylase level may be elevated, with associated traumatic pancreatitis or obstruction of the duct of Wirsung. The icterus index rises, depending on the amount of mechanical interference to bile flow. Indirect bilirubin elevation due to blood resorption also may be detected [2,21]. A high hematocrit value, due to dehydration as well as dislocation of electrolytes, may be noted. Hemorrhagic studies reveal the bleeding diathesis, and the laboratory demonstration of pancreatitis is extremely reliable.
11-15
16-X
21-25
26-X
31-35
36-K
FIG. 4. Leukocyte count (given in thousands per cu. mm.) in one hundred cases of intramural hcmatoma of duodenum and jcjunurn.
Intramural defined mass [3,10]; (4) a crescent-shaped air shadow [5 1; or (5) fluid levels in the paralyzed loop. The upper gastrointestinal series is demonstrative. Liverud [3] described what Felson and Levin 14) termed the “coiled spring” sign, which represents an intramural extramucosal mass with crowding of the valvulae conniventes. An associated extrinsic defect of the greater curvature may be noted. Schoo’s case demonstrates that the “coiled spring” sign occurs only if intussusception of the dissected mucosa is present I7.91. In cases involving mucosal ulceration, barium collects in these pockets, causing most radiologists to prefer a water-soluble radiopayue medium. In cases involving bleeding diathesis, several physicians have described the “picket fence” appearance [WI, consisting of rigid, thickened mucosa with narrowing of the lumen and absence of the longitudinal folds. Mild extrinsic pressure and narrow spikes on the duodenal margin complete the picture. This is explained pathologically by a more diffuse infiltration of the wall by noncoagulable blood. The experimental picture reproduced by Felson and Levin [4] was similar to this description. An intravenous pyelogram may show a lateral displacement of the ureter, which could be taken as another clue pointing to the presence of this retroperitoneal lesion. DIFFERENTIAL
DIAGNOSIS
Intramural hematomas should be differentiated from other lesions. In intussusception, aside from a difference in the patient’s history, a shortening of the duodenum with a constricted lumen and without eccentricity is noted [4]. The “coiled spring” sign will be absent in these cases. An extramucosal neoplasm would have an insidious character and have no “coiled spring” sign, unless it is intussuscepted [17]. Kupture of organs usually is associated with a deteriorating clinical picture and typical changes as noted on laboratory findings. In our revie\v we noted that several patients were operated on for appendicitis, falsely suggested by the moderately elevated leukocyte count and the vague history. COURSE
.ZNI)
COMPLICATIONS
Sotne hematomas undergo spontaneous absorption, whereas others burst spontaneously into the peritoneal cavity. Several cases were
Hematoma
1-4.X3
reported in which fibrous organization of the clot occurred. This ranged from fibroblastic proliferation seen microscopically to stenosing obstruction [ZO] with small bands (221 as an intermediate. TREATMENT
The cause must be established prior tcl any treattnent since an operation may be disastrous in patients with bleeding tendencies [17]. In cases of trauma some authors believe that a ten day waiting period with conservative treatment should be tried prior to any surgery. In view of our experience and review of the literature and in consideration of the simplicity of the operation, we strongly believe that surgical intervention is the procedure of choice. Such treatment not only affords a definite evaluation of the lesions but also avoids prolonged morbidity. A Kocher maneuver is essential. For further visualization the ligament of Treitz may have to be transected. The usual treatment consists in the evacuation of the clot, with or without suturing of the serosa. We do not believe that a drain should be used since it may produce plication of the denuded mucosa, resulting in a diaphragmatic type of obstruction [7]. When the patency of the bowel is in doubt, a gastroenterostomy may be performed in conjunction with the evacuation of the blood clot. Some authors pass a Levin tube beyond the lesion to the jejunum, Resection of the affected bowel has been carried out in several instances when its viability was questionable [6]. The postoperative course generally is uneventful. Some patients, however, have recurrent obstruction, which could be due to incomplete evacuation of the blood clot or to recurrence of bleeding. SUMMARY
Three new cases reported herein and ninetyseven cases from the literature reveal that intramural hematomas of the duodenum and jejunum are not as rare as the early literature would indicate. These hematomas are characterized by upper gastrointestinal obstruction that occurs generally after trauma or they are associated with a bleeding tendency. A mass is frequently present. There is low grade leukocytosis. Radiographic studies often are pathognomonic. The hematoma may or may not be resorbed and may give rise to chronic obstruction. Treatment should consist of simple surgical evacuation of the clot without drainage. A
954 gastroenterostomy evacuation.
Devroede,
Tirol,
Lo Russo,
may be associated with the
Acknowledgment: Dr. James Jackman supplied the radiologic diagnosis on the first patient. REFERENCES 1, MCLAUCHLAN, J. Fatal false aneurysmal tumour occupying nearly the whole of the duodenum. Lance& 2: 203, 1838. 2. GUIBO, M. Contusions et ruptures traumatiques du duod&um. Real. gynbc. et chir. ahd., 15: 223, 349, 1910. 3. LIVERUD, K. Hematoma of the jejunum with subileus. Acta rudiol., 30: 163, 1948. 4. FELSON, B. and LEVIN, E. J. Intramural hematoma of the duodenum: diagnostic roentgen sign. Radiology, 63: 823, 1954. 5, JUDD, D. R., TAYRI, H., and KING, H. Intramural hematoma of the small bowel: a report of two cases and a review of the literature. birch. Surg., 89: 527, 1964. 6. MOORE, S. W. and ERLANDSON,M. E. Intramural hematoma of the duodenum. clnn. Surg., 157: 798, 1963. 7. ROWE, E. B., BAXTER, M. R., and ROLE, C. W. Intramural hematoma of the duodenum: report of a case with an unusual complication. Llrch. Surg., i8:560, 1959. 8. SENTURIA, H. R., SUSMAN, N., and SHYKEN, H. The roentgen appearance of spontaneous intramural hemorrhage of the small intestine associated with anticoagulant therapy. ..l-lm.J. Roentgenol., 86: 62, 1961. 9. SCHOO, B. H. Intramural hematoma causing intestinal obstruction. J. Kentucky M. .I., 61: 28, 1963. 10. SILBERT, B., FIGIEL, L. S., and FIGIEL, S. J. Intramural jejunal hematomas secondary to anticoagulant therapy. Anz. J. Digest Dis., 7:892, 1962.
and Narducci
11. SMITH, R. P. Intestinal obstruction due to submucosal hcmatoma of the jejunum in the newborn. J. Kansas hf. Sm., 40: 16, 1939. 12. HIEBEL, G., LANG, G., and FONTAINE. R. Tntraparietal duodenal hematomns: apropos of a case of spontaneous pancreatic origin. , Irrh. ma!. app. digest., 51: 1012, 1962. 13. JONES, G. E. and SETTLE, J. W., JR. Obstructing lesion of the colon due to non-penetrating trauma of the abdomen. Northwest Aled., 51: 317, 1952. 14. KERRY, R. L. and GLAS, W. W. Traumatic injuries to the pancreas and duodenum: a clinical and experimental study. _-Ivch. Surf., 85: 813, 1962. 15. KISSEL, P., RAUBERG, G.. DUREU~, J. B., SCHMITT, J., and MARCHAL, C. L. l_‘ne ktiologic rare de stenose duodenale: l’h&atome intrapariCta1 d’origine pancrbatique. .-Inn. m@d. Naanry, 3: 984, 1963. 16. WHITE, R. J. and WoLLE!ihIAN. 0. J. il case of intestinal obstruction from spontaneous subserosal hemorrhage with angiomatous malformation associated with reduplication of the jejunum. Ann. Sung., 143: 720, 1956. li. WIOT, J. F., WEINSTEIN, A. S., and FELSON, B. Duodenal hematoma induced by coumarin. Am. J. Roentgenol., 86: 70, 1961. 18. SPENCER, R., BATEMAS, J. D.. and HORN, P. L. Intramural hematoma of the intestine, a rare cause of intestinal obstruction: review of the literature and report of a case. Suvgrr_~, 41: 794, 1952. 19. SPANGLER, H. iiber subkutane Diimldarmrupturen. II-ien. med. Tl.chnschr., 108: 1014, 1958. 20. CULVER, G. J. and PIRSON, H. S. Intramural hcmatoma of the jejunum: a case report. ‘1%. J. Roentgenol., 90: 732, 1963. 21. FERGUSON, I. A., JR. and GOADE, W. J.. JR. Intramural hematoma of the duodenum: report of a case. Nez~ England J. Med., 260: 1176, 1959. 22. CULVER, G. J., PIRSON, H. S., MILCH, E., BERMAN, L., and ABRANTES, F. J, Intramural hematoma of the jejunum: a case report. Radiology, 76: 785, 1961.