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Intramural small intestinal hemorrhage—A differential diagnosis
Intramural
Small Intestinal Hemorrhage A Differential Diagnosis By JEROME F. WIOT, M.D.
I
NTRAMURAL small intestinal hemorrhage produces a dramatic but not always diagnostic roentgenographic appearance. The hemorrhage may be traumatic in origin or secondary to a variety of diseases associated with a bleeding tendency. There is also a iatrogenic form resulting from anticoagu lant intoxication. A similar roentgen pattern may be produced by certain nonhemorrhagic diseases of the small bowel, and their identification is necessary so that therapy is properly directed. The history of intramural intestinal hemorrhage is old, even though its roentgen recognition is but recent. McLaughlin, in 1836, was apparently the first to describe duodenal hematoma .37 He noted at the autopsy table a case of “false aneurysm” of the first and second portions of the duodenum which had resulted in obstruction. The cause was not apparent. In 1894, Perry and Shaw described at autopsy a hematoma of the duodenum which followed a fa11.48 Although additional cases were found at laparotomy or autopsy,*~**~ 44,50,63*64,6Q a roentgen description did not appear until 1948, when Liverud described a case involving the jejunum found at surgery.34 A preoperative diagnosis of benign tumor had been made. The first detailed roentgen description as well as the first correct preoperative diagnosis were by Felson and Levin in 1954.15 Since then, over 45 articles and 80 cases have been reported, an indication of the frequency of and interest in this entity.2~3~5~912,16.13.20,21,23-27,30-32,36,38-43,45-47,49,51-54,6G-61,65-68,i0,71
Intramural intestinal hemorrhage produces two types of roentgen manifestations: those related to a localized intramural mass and those of diffuse infiltration of the wall. In the traumatic form, both are present, whereas with the spontaneous form, the mass is not seen, The explanation for this difference is not clear. Perhaps with trauma, larger vessels are injured, resulting in a more localized hematoma, whereas with the spontaneous form, the process is more diffuse and from smaller vessels. The failure of clotting may also play a significant role in some of the cases with spontaneous bleeding. Because of their difference in roentgen pattern, it is important to discuss these two forms of hematoma separately. TRAUMATIC INTRAMURAL HEMATOMA
The traumatic form of hematoma has been clearly described both surgically and roentgenologically. Felson and Levin,15 in their report of four traumatic cases, included a subtitle: “A Diagnostic Roentgen Sign.” This _~--~-__~~.JEROME F. WIOT, College of Medicine Cincinnati.
M.D.: Associate Professor of Radiology, University of Cincinnati and Associate Director of Radiology, Cincinnati General Hospital, 219 SEMINAFIS IN ROE~TGENOLOCY,VOL.
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(APRIL),
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statement has been borne out, since many additional traumatic cases have now been reported, all showing these findings, and they have been encountered in no other condition. As might be suspected, the majority of patients were children, with boys showing a marked preponderance. Although a history of trauma can usually be obtained, it must be diligently sought, as in many reported cases the injury was so mild as to have been forgotten or overlooked. One patient was a butcher who apparently sustained the injury while carrying a large slab of meat- an everyday activity in this occupation. The majority of cases related to trauma have involved the duodenum. Judd et a12’ reviewed 46 cases of traumatic hematoma and added 2 of their own. In 45 of the 48 cases, the site was mentioned. The duodenum alone was involved in 26, the jejunum in 9, and both in 10. Spencer et al.,s1 in a review of 34 cases, found 17 in the duodenum and 8 in the colon, 5 in the for the dujejunum, 3 in the ileum and 1 esophageal. The predilection odenum is attributed to its fixation at the suspensory ligament, the trauma “slapping” or compressing the duodenum against the spine. A similar situation at the pelvic brim probably accounts for the relatively high incidence of hematoma also noted in the ileocecal area. As mentioned, the roentgen pattern of traumatic hematoma is diagnostic. The plain film findings are nonspecific and consist of obstructive or nonobstructive distention, Uncommonly, an ill-defined intraluminal mass in a distended loop of bowel may be seen. The psoas shadow is often obliterated in cases involving the duodenum, again a not too helpful sign. With the administration of contrast medium, a relatively short segment of involvement (about lo-20 cm. in length) is seen. Proximally, the affected intestine may show only thickening and coarseness of the mucosal folds (Fig. la). More distally, an intramural mass appears to widen the lumen (Fig. 1B). The valvulae conniventes in the area are crowded together, producing a “coilspring” appearance reminiscent of that seen in intussusception (Fig. 2). Obstruction is, as a rule, only partial. Extrinsic pressure upon surrounding structures is often present. The mass represents the hematoma itself. The coarsening and coilspring pattern of the mucosa adjacent to the mass are secondary to the intramural diffusion of the blood. It is this combination of mass and coilspring pattern that is pathognomomic. SPONTANEDUSINTRAMURALHEMATOMA
The reported causes of spontaneous intramural intestinal hemorrhage inintoxication 2.4.9,18,21,23,24,30,32,45,4~,62,56,67~50,70 hemoclude anticoagulant philia,30*7i thrombocytopenic Henoch’s purpura,14*17v30 purpurpura,30 pura associated with leukemia and other malignancies,“O hypoprothrombinemia of severe liver disease,70 an obscure bleeding diathesis in an infant,22 and a single case report of pancreatitis. 3o In 1959, Katz reported 25 cases of ‘hemorrhagic duodenitis” found at autopsy in patients with myocardial infarction.28
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intramural hematoma of the duodenum. (A) The ITIUCosal Fig ;. L-Traumatic folds proximal to the mass (arrow) are coarse and thick. (B) The hematoma in the m,ass. of an intramural distal duodenum presents all the roentgen manifestations (Rep] -educed with permission of Radiology.15)
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Fig. 2. -Traumatic hematoma in two different patients. The character istic : coilspring Pa.tiem is clearly shown (arrows). Note the widening of the lum en. (A is reprod uct ?d with permission of Radiology.15)
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Fig. X-Coumarin intoxication with picket fence or stacked coin appearance. Note the difference from the coilspring in Figure 2. (Reproduced with permission of Amer. J. Roentgen.70) Although spontaneous intramural hematoma of the gut had been described as early as 1908, 2g the roentgen manifestations were not elucidated until 1961, when back-to-back articles by Senturia et a1.57 and Wiot et al.‘O appeared. These authors described the roentgen signs in a total of 5 cases of small intestinal hematoma resulting from excessive anticoagulant therapy: 2 in the duodenum, 2 in the jejunum and 1 in the ileum. Since then, over 20 more cases related to anticoagulant therapy and a number caused by hemophilia and other conditions associated with spontaneous bleeding have been described. In a recent article by Khilnani et a1.,30 the roentgen signs were beautifully demonstrated and attention was called to the similarity of the roentgen pattern regardless of the cause of the spontaneous hemorrhage. Unlike the traumatic form, in which a mass is generally identified, spontaneous hematoma presents more of an infiltrative pattern. The involved segment has no particular predilection for the duodenal area but may occur anywhere in the small or large bowel, often extending over a considerable length
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Fig. 4.-A young hemophiliac with a hematoma of the jejunum. “Thumbprinting” (arrow), as described with vascular occlusion, accompanies the picket fence pattern.
of gut. The affected loop is rigid and, at fluoroscopy, moves as a unit. The mucosal folds are thick and the troughs between them narrow, a pattern which persists throughout the examination. The normal feathery appearance of the mucosa is lost, as are the longitudinal folds, and the margins of the bowel show spikes of varying height (Fig. 3). Although quite similar in derivation to the coilspring of the traumatic cases, it has been likened to stacked coins by Khilnani et aL30 and to a picket fence by Wiot et al.‘O “Thumbprinting” or pseudotumor formation, as described by SchwartzK6 in connection with arterial occlusion, is also frequent (Fig. 4). However, the type of localized intramural mass seen in traumatic hematoma has not been encountered. Depending on the magnitude of the hemorrhage, the lumen may or may not be significantly narrowed. Extrinsic pressure on adjacent structures may result not only from hemorrhage in the bowel wall itself but also from blood within the adjacent mesentery.
225
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Fig. 5.-Specimen of small intestine which has been injected intramurally with water. The pattern resembles closely those seen in Figures 3 and 4. (Reproduced
with permission of Radiology.) If the cause of the spontaneous hemorrhage can be corrected, e.g. by discontinuing the drug in patients with anticoagulant intoxication, the roentgen picture gradually returns to normal over the next two or three weeks, DIFFERENTIAL
DIAGNOSIS
As previously stated, the combination of mass and coilspring pattern seen in traumatic hematoma is pathognomonic. The coilspring pattern of intussusception is accompanied by shortening of the intestine. This telescoping would be especially obvious in such a well defined segment as the duodenum. Many authorities suggest that the roentgen pattern of the nontraumatic form of hematoma is also diagnostic, and attempts have been made to distinguish one form of spontaneous bleeding from another by minor differences in the roentgen findings. I do not share these beliefs. The coilspring, stacked coin, or picket fence pattern produced by nontraumatic hematoma results from the relatively diffuse infiltration of a segment of the intestinal wall by liquid blood. In like manner, any other soft or fluid substance which diffusely infiltrates a segment of intestine may produce a similar if not identical pattern. Felson and Levin13r injected the wall of an isolated bariumfilled segment of small bowel with water. The resulting roentgenogram showed the “characteristic” pattern of spontaneous hematoma (Fig. 5). No localized mass was evident. Any condition causing relatively localized intramural thickening of the bowel, such as interloop abscess (Fig. 6) or pancreatitis (Fig. 7) or infarction (Fig. lo), is capable of producing the same appearance. Intestinal edema might also be expected to cause this pattern. Marshak and Lindner, elsewhere in this issue (Fig. 20), illustrate a patient with nephrosis in whom a mild form of the pattern with a more diffuse distribution is seen. FrimannDahPQ demonstrates a case of phlegmonous jejunitis and another with small bowel obstruction in which the picket fence appearance is well seen. Diffuse
Fig, I &--Small intestinal changes secondary to interloop abscess. (A) Rklptu lred (B) Tubovaria: n abscbess. aPPe” dix. Changes are most striking in left mid-abdomen. Note 1humbprinting. 226
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Fig. ‘I.-Changes
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in duodenojejunal
area in acute pancreatitis.
infiltration of a segment of gut wall by neoplastic cells (Fig. 8), or by soft structural abnormalities, such as lymphangiectasia ( Fig. 9) ,” under appropriate circumstances may produce similar changes. In none of these conditions, then, are the roentgen signs alone adequate for diagnosis. The clinical findings are often but not always decisive. Evidence of a bleeding tendency, a history of anticoagulant treatment, signs and laboratory evidence of pancreatitis, auricular fibrillation, etc.-all of these are inportant leads. Just to bring one of the problems into focus, the differentiation between mesenteric infarction and intramural hematoma is of obvious importance; yet, given an elderly cardiac patient with vascular disease who is receiving anticoagulant therapy and develops intestinal bleeding, abdom--“See also Fig. 18 in the article by Marshak
and Lindner,
elsewhere
in this issue.
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F. WIOT
Fig. (P.-Three patie :nts with terminal ileum cha nges. What is your diag nosis? See legend of Fig ure 9 for answer.
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Fig. 9.-Changes resembling intramural hematoma but caused by lymphangiectasia. Answers to Fig. 8: (A) Mesenteric infarction. (B) Carcinoid. (C) Hematoma in a hemophiliac. inal pain, and even shock, does he have mesenteric infarction or intramural hematoma (Fig. lo)? The roentgen signs of the two are similar and, with either, a rapid return to a completely normal roentgen appearance may occur. But with mesenteric infarction, surgical intervention may be life-savintoxication it is life-threatening. While ing, while with anticoagulant Khilnani et al.“O pointed out certain subtle differences in the roentgen signs, with spasm, irritability, lack of a mesenteric mass and edema pointing towards mesenteric infarction, in my own experience these signs have seldom been of help. Despite these problems, the recognition of the stacked coin pattern is im-
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Fig. 10. (A) Cardiac patient on coumarin. Does he have mesenteric infarction or hematoma? (Fig. A is dated 6/24/63.) (B) Note return to normal after five days.
(C) Same patient four months later. Proved mesenteric artery occlusion. portant. Although the specific cause of the abnormality may be uncertain, established the nature of the pathologic process- intramural infiltration-is and limits the number of possibilities. Clinical features may then be utilized for differential diagnosis. SUMMARY
Intramural small intestinal hemorrhage has many causes but produces only two roentgenographic patterns. In one, the traumatic form, the pattern is
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diagnostic if all the manifestations are recognized. In the spontaneous form, however, the pattern is almost identical with the appearance of certain nonhemorrhagic conditions. Recognition of this stacked coin or picket fence appearance limits the diagnostic possibilities, and differentiation can usually be established by clinical and laboratory findings. ACKNOWLEDGMENTS The author expresses his sincere gratitude to Dr. Benjamin Felson for his suggestions and advice and to Mr. Jerry Chamberlin for his assistance. Thanks is also given to Dr. Harold Margolin for permission to use Figure 8C and to Dr. Stanley Nedehnan for Figure 10. REFERENCES 1. Barnes, C. G., and Duncan, G. W.: Anaphylactoid purpura simulating acute regional ileitis. Brit. J. Surg. 29: 253-255, 1941. 2. Beamish, It. E., and McCreath, N. D.: Intestinal obstruction complicating anticoagulant therapy. Lancet 2:390-392, 1961. 3. Bergman, B. J., and Crowson. C. N.: Intramural hematoma of the duodenum; report of a case with review of the literature. Med Serv. J. Canada 15:449-456, 1959. 4. Berman, H., and Mainella, F. S.: Toxic results of anticoagulant therapy. New York J. Med. 52:725-727, 1952. 5. Bertelsen, S.: Intramural hematoma of the duodenum. Acta Chir. Stand. 128: 556-563, 1964. 6. Brust, N. M.: Ileo-ileal intussusception associated with Henoch-Schonlein’s purpura; report of case with discussion. Arch. Pediat. 69:212-218, 1952. 7. Caird, D. hl., and Ellis, H.: Intramural haematoma of the duodenum. A report of a case and a review of the literature. Brit. J. Surg. 45:389-391, 1958. 8. Cooling, C. I.: Subserous duodenal hematoma. Brit. Med. J. 1:1051, 1953. 9. Culver, G. J., Pirson. H. S., Melch. E., Berman, L., and Abrantes, F. J.: Intramural hematoma of the jejunum. Radiology 76:785-789, 1961. 10. Culver, G. J., and Pirson, H. S.: Intramural hematoma of the duodenum. Amer. J. Roentgen. 82:1032-1035, 1959. 11. Culver, G. J., and Pirson, H. S.: Intramural hematoma of jejunum: case report. Amer. J. Roentgen. 90:732-734, 1963.
12. Davis, D. Il., and Thomas, C. Y.: Intramural hematoma of the duodenum and jejunum: a cause of high intestinal obstruction-Report of three cases due to trauma. Amer. Surg. 153:394398, 1961. 13. Dey, D. L.: Acute duodenal obstruction due to an intramural haematoma. Med. J. Australia 1:708, 1952: 14. Esposito, J. J.: Small intestinal abnormalities in anaphylactoid purpura. Radiology 55:548-552, 1950. 15. Felson, B., and Levin, E. J.: Intramural hematoma of the duodenum. Radiology 633823-831, 1954. 16. Ferguson, I. A., and Goade, W. J., Jr.: Intramural hematoma of the duodenum. New Eng. J. Med. 260:11761177, 1959. 17. Fetter, J. S., and Mills, W. L.: Roentgenographic findings in SchonleinHenoch’s purpura. Radiology 55:545547,195o. 18. Frieden, J. H., and Kaplan, L.: An intestinal complication of anticoagulant therapy. Calif. Med. 98:159-161, 1963. 19. Frimann-Dahl, J,: Roentgen Examinations In Acute Abdominal Diseases. Springfield, Ill., C. C Thomas, 1960. 20. Garfinkel, B., Waleson, M., and Furst, N. J.: Hematoma of the duodenum. Amer. J. Surg. 95:484486, 1958. 21. Gilbert. A. E., and Jorgenson, N. C.: Small bowel obstruction due to hemorrhage secondary to anticoagulant therapy. Amer. J. Surg. 99:945948. 1960. 22. Class, G. C.: Hemorrhage in a newly born infant, causing intestinal and biliary obstruction. Report of a case with necropsy. Amer. J. Dis. Child. 54:1052c1056, 1937.
232 23. Goldfarb, W. B.: Coumarin-induced intestinal obstruction. Ann. Surg. 161: 2734, 1965. 24. Golding, M. R., DeJong, P., and Parker, J. W.: Intramural hematoma of the duodenum. Ann. Surg. 157:573-578, 1963. 25. Gordon, W. B., Howell, J. F., and Gordon, J. R.: A rare cause of intestinal obstruction: traumatic intramural hematoma associated with leiomyoma of the jejunum. Report of a case. Arch. Surg. 78:556-569, 1959. 26. Izant, R. J.. Jr., et al.: Duodenal obstruction due to intramural hematom:! in children. J. Trauma 4:797-813. 1964. 27. Judd, D. R., Taybi, H., and King, H.: Intramural hematoma of the small bowel. Arch. Surg. 89:527-535, 1964. 28. Katz, A. M.: Hemorrhagic duodenitis in myocardial infarction. Ann. Intern. Med. 51:212-218, 1959. 29. Khautzjun, A. von: Darmstenose durch submucose Hamatome bei Hamaphilit. Arch. Klin. Chir. 87:542-551, 1908. 30. Khilnani, hf. T.. hfarshak, R. H., Eliasoph, J., and Wolf, B. S.: Intramural intestinal hemorrhage. Amer. J, Roentgen. 92: 1061-1071, 1964. 31. Kirkpatrick, W. E.: Submucosal hematoma of the duodenum: discussion and report of a case. Amer. J. Roentgen. 83:857-860, 1960. 32. Kramer. R. A.. et al.: Intramural small bowel bleeding during anticoagulant therapy. Arch. Intern. Med. 113:213217. 1964. 33. Lampert. E. (7.. Goodfellow. J. G., and Wachowski. T. J.: Traumatic subserosal hemorrhage causing small bowel obstruction. Ann. Surg. 140:768-770, 1954. 34. Liver&. K.: Hematoma of the jejunum with subileus. Acta Radiol. 30:163168. 1948. 33. Magladry. G. W.. Jr., and Mathewson. G., Jr.: Duodenal obstruction due to trauma. Stanford Med. Bull. 12:205206. 1954. 36. McClelland, J. R., Thistlethwaite, J. R., and Gerwig. W. H., Jr.: Obstruction of the distal duodenum due to intramural hemorrhage. Amer. Surg. 24:
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367-370, 1958. 37. McLaughlin, J.: False aneurysmal tumor occupying nearly whole of duodenum. Lancet 2:203-205. 1838. 38. McIntyre. J. A., and hlcIntyre, J. A.: Acute duodenal obstruction secondar! to hematoma. Canad. J. Surg. 5:324328. 1962. 39. Melamed. hI.. and Pantone. A. M.: Hematoma of the duodenum. Radiolog! 66:874-875. 1956. 40. h,festel. A. L.. et al.: Acute obstruction of small intestine secondary to hematoma in children. Arch. Surg. 78:2532. 1959. 41. hlirov. A. G.: Intramural hematoma of the dllodenum. Surgery 51:434-436. 1962. 42. Mood ._ E. E.: Acute jejunal obstruction secondary to traumatic intramural hematoma. Pediatrics 19:863-868. 1997. 43. hloore. S. W.. and Erlandson. hl. E.: Intramural hematoma of the duodenum. Ann. Sure;. 157:798-809, 1963. 44. Opnenheimer. G. D.: Acute obstruction of the duodenum due to submucous haematomn. Ann. Snrg. 98:192-196. 193.3. 45. Parrish. R. .4.: Intestinal obstruction: a complication of anticoagulant therapy. Amer. 1. Surg. 97:782. 1959. 46. Patton. T. B.: Duodenal injury due to trauma. nonpenetrating abdominal Amer. Surg. 23:587-593. 1957. 47. Pearson. S., and MacKenzie, R. J.: Intestinal obstruction due to bishydroxy coumarin (Dicumerol) poisoning. J. A. hf. A. 167:455-456. 1958. 48. Perry. E. C.. ancl Shaw. L. E.: On diseases of duodenum. Guy Hosp. Rep. 50: 1X-308. 1893. 49. Pester. G. H.. and Peartree, P.: Traumatic intramural hematoma of the duodenum. Amer. J. Surg. 96:568-570. 1958. 50. Platou. E. S.. and Platou. R. V.: Hemophilia with intestinal obstruction. hlinn. Med. 23:857. 1940. 51. Robarts. F. H.: Traumatic intramural hemntoma of proximal jejunal loop. A. M. i\. J. Dis. Child. 323484-487. 1957. 52. Robertson, C. W.. and Javett, S.: Small bowel obstruction due to spontaneous intramural hematoma: a rare complication of long term anticoagulant
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53.
54.
53.
56.
57.
58.
59.
60.
61.
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therapy. Proc. N. Eng. Cardiovasc. Sot. 21: 19. 1962-63. Rowe. E. B.. Baxter, M. R.. and Rowe, C. W.: Intramural hematoma of the duodenum. Report of a case with an unusual complication. Arch. Surg. 78: 560-564. 1959. Schoo. B. J.: Intramural hematoma causing intestinal obstruction. J. Kentucky Med. Assn. 61:28-30, 1963. Schwartz. S.. Boley, S. J.. Robinson, K.. Krieger, H., Schultz. L.. and Allen, A. C.: Roentgenologic features of vascular disorders of the intestines. Radiol. Clin. N. Amer. 2:71-87. 1964. Sears. A. D.. Hawkins, J.. Kilgore, B. B.. and Miller, J. E.: Plain roentgenographic findings in drug induced intramural hematoma of the small bowel. Amer. J, Roentgen. 91:808-813. 1965. Senturia. H. R.. Susman. N.. and Shyken. H.: The roentgen appearance of spontaneous intramural hemorrhage of the small intestine associated with anticoagulant therapy. Amer. J. Roentgen. 86:62-69, 1961. Shaw, A.. and Cinque. S.: Traumatic intramural hematoma. An uncommon cause of intestinal obstruction in children. case report and review of literature. Amer. J. Dis. Child. 108:667673, 1964. Silhert. B.. Figiel, L. S.. and Figiel. S. J.: Intramural jejunal hematomas secto anti-coagulant therapy. ondary Amer. J. Dig. Dis. 7:892-899. 1962. Snider, H. R.: Acute duodenal obstruction secondary to intramural hematoma. Surgery 33:860-864. 1956. Spencer, R., Bateman. J. D., and Horn. P. L.: Intramural hematoma of the intestine. a rare cause of intestinal obstruction. Review of the literature and
62. 63.
64.
65.
66.
67.
68.
69.
73.
71.
7”.
report of a case. Surgery 41:794-804. 1957. Stirk, D. L.: Case of subserous duodenal haematoma. Brit. Med. J. 1:712, 1953. Strachan, F. J.: Traumatic obstruction of the duodenum: operation and recovery. Brit. hIed. J. 2:592. 1920. Sutherland. G. A.: Intussusception and Henoch’s purpura. Brit. J. Child. Dis. 1:23-28, 1904. Swaiman. K. F., Root. J. F.. and Raile. R. B.: Coil-spring sign and intramural hematoma of proximal small intestine. A. M. A. J. Dis. Child. 95:413-416. 1958. Watanabe. L. J., and Inouye. hl. R.: Duodenal obstruction due to intramural hematoma. Calif. Med. 85:254256, 1956. Watne, A. L.. Butz. G. R.. and Tarnay. T. J.: Duodenal obstruction due to intramural hematoma. Arch. Surg. 89: 441-445. 1964. White. R. J.. and Wollenman, 0. J.: Case of intestinal obstruction from spontaneous subserosal hemorrhage with angiomatous malformation associated with reduplication of jejunum. Ann. Surg. 143:720-724, 1956. Whitmore. W. H., and Peterson, G. hi.: Henoch’s purpura: small intestinal changes. Radiology 46:373-376, 1946. Wiot. J. F.. Weinstein, A. S.. and Felson. B.: Duodenal hemntoma induced by coumarin. Amer. J. Roentgen. 86: 70-75, 1961. Wolf, B. S.: Case #29 Intramural hematoma of terminal ileum and ileocecal valve due to hemophilia. J. Mt. Sinai Hosp. 25:89-93, 1958. Zabin. A.: Acute intramural jejunal hemorrhage. New York J. bled. 52:93, 1952.
Small Intestinal Hemorrhage A Differential Diagnosis By JEROME F. WIOT, M.D.
I
NTRAMURAL small intestinal hemorrhage produces a dramatic but not always diagnostic roentgenographic appearance. The hemorrhage may be traumatic in origin or secondary to a variety of diseases associated with a bleeding tendency. There is also a iatrogenic form resulting from anticoagu lant intoxication. A similar roentgen pattern may be produced by certain nonhemorrhagic diseases of the small bowel, and their identification is necessary so that therapy is properly directed. The history of intramural intestinal hemorrhage is old, even though its roentgen recognition is but recent. McLaughlin, in 1836, was apparently the first to describe duodenal hematoma .37 He noted at the autopsy table a case of “false aneurysm” of the first and second portions of the duodenum which had resulted in obstruction. The cause was not apparent. In 1894, Perry and Shaw described at autopsy a hematoma of the duodenum which followed a fa11.48 Although additional cases were found at laparotomy or autopsy,*~**~ 44,50,63*64,6Q a roentgen description did not appear until 1948, when Liverud described a case involving the jejunum found at surgery.34 A preoperative diagnosis of benign tumor had been made. The first detailed roentgen description as well as the first correct preoperative diagnosis were by Felson and Levin in 1954.15 Since then, over 45 articles and 80 cases have been reported, an indication of the frequency of and interest in this entity.2~3~5~912,16.13.20,21,23-27,30-32,36,38-43,45-47,49,51-54,6G-61,65-68,i0,71
Intramural intestinal hemorrhage produces two types of roentgen manifestations: those related to a localized intramural mass and those of diffuse infiltration of the wall. In the traumatic form, both are present, whereas with the spontaneous form, the mass is not seen, The explanation for this difference is not clear. Perhaps with trauma, larger vessels are injured, resulting in a more localized hematoma, whereas with the spontaneous form, the process is more diffuse and from smaller vessels. The failure of clotting may also play a significant role in some of the cases with spontaneous bleeding. Because of their difference in roentgen pattern, it is important to discuss these two forms of hematoma separately. TRAUMATIC INTRAMURAL HEMATOMA
The traumatic form of hematoma has been clearly described both surgically and roentgenologically. Felson and Levin,15 in their report of four traumatic cases, included a subtitle: “A Diagnostic Roentgen Sign.” This _~--~-__~~.JEROME F. WIOT, College of Medicine Cincinnati.
M.D.: Associate Professor of Radiology, University of Cincinnati and Associate Director of Radiology, Cincinnati General Hospital, 219 SEMINAFIS IN ROE~TGENOLOCY,VOL.
1, ~0.2
(APRIL),
1966
220
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F. WIOT
statement has been borne out, since many additional traumatic cases have now been reported, all showing these findings, and they have been encountered in no other condition. As might be suspected, the majority of patients were children, with boys showing a marked preponderance. Although a history of trauma can usually be obtained, it must be diligently sought, as in many reported cases the injury was so mild as to have been forgotten or overlooked. One patient was a butcher who apparently sustained the injury while carrying a large slab of meat- an everyday activity in this occupation. The majority of cases related to trauma have involved the duodenum. Judd et a12’ reviewed 46 cases of traumatic hematoma and added 2 of their own. In 45 of the 48 cases, the site was mentioned. The duodenum alone was involved in 26, the jejunum in 9, and both in 10. Spencer et al.,s1 in a review of 34 cases, found 17 in the duodenum and 8 in the colon, 5 in the for the dujejunum, 3 in the ileum and 1 esophageal. The predilection odenum is attributed to its fixation at the suspensory ligament, the trauma “slapping” or compressing the duodenum against the spine. A similar situation at the pelvic brim probably accounts for the relatively high incidence of hematoma also noted in the ileocecal area. As mentioned, the roentgen pattern of traumatic hematoma is diagnostic. The plain film findings are nonspecific and consist of obstructive or nonobstructive distention, Uncommonly, an ill-defined intraluminal mass in a distended loop of bowel may be seen. The psoas shadow is often obliterated in cases involving the duodenum, again a not too helpful sign. With the administration of contrast medium, a relatively short segment of involvement (about lo-20 cm. in length) is seen. Proximally, the affected intestine may show only thickening and coarseness of the mucosal folds (Fig. la). More distally, an intramural mass appears to widen the lumen (Fig. 1B). The valvulae conniventes in the area are crowded together, producing a “coilspring” appearance reminiscent of that seen in intussusception (Fig. 2). Obstruction is, as a rule, only partial. Extrinsic pressure upon surrounding structures is often present. The mass represents the hematoma itself. The coarsening and coilspring pattern of the mucosa adjacent to the mass are secondary to the intramural diffusion of the blood. It is this combination of mass and coilspring pattern that is pathognomomic. SPONTANEDUSINTRAMURALHEMATOMA
The reported causes of spontaneous intramural intestinal hemorrhage inintoxication 2.4.9,18,21,23,24,30,32,45,4~,62,56,67~50,70 hemoclude anticoagulant philia,30*7i thrombocytopenic Henoch’s purpura,14*17v30 purpurpura,30 pura associated with leukemia and other malignancies,“O hypoprothrombinemia of severe liver disease,70 an obscure bleeding diathesis in an infant,22 and a single case report of pancreatitis. 3o In 1959, Katz reported 25 cases of ‘hemorrhagic duodenitis” found at autopsy in patients with myocardial infarction.28
1NTRAMuRAL
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intramural hematoma of the duodenum. (A) The ITIUCosal Fig ;. L-Traumatic folds proximal to the mass (arrow) are coarse and thick. (B) The hematoma in the m,ass. of an intramural distal duodenum presents all the roentgen manifestations (Rep] -educed with permission of Radiology.15)
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Fig. 2. -Traumatic hematoma in two different patients. The character istic : coilspring Pa.tiem is clearly shown (arrows). Note the widening of the lum en. (A is reprod uct ?d with permission of Radiology.15)
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Fig. X-Coumarin intoxication with picket fence or stacked coin appearance. Note the difference from the coilspring in Figure 2. (Reproduced with permission of Amer. J. Roentgen.70) Although spontaneous intramural hematoma of the gut had been described as early as 1908, 2g the roentgen manifestations were not elucidated until 1961, when back-to-back articles by Senturia et a1.57 and Wiot et al.‘O appeared. These authors described the roentgen signs in a total of 5 cases of small intestinal hematoma resulting from excessive anticoagulant therapy: 2 in the duodenum, 2 in the jejunum and 1 in the ileum. Since then, over 20 more cases related to anticoagulant therapy and a number caused by hemophilia and other conditions associated with spontaneous bleeding have been described. In a recent article by Khilnani et a1.,30 the roentgen signs were beautifully demonstrated and attention was called to the similarity of the roentgen pattern regardless of the cause of the spontaneous hemorrhage. Unlike the traumatic form, in which a mass is generally identified, spontaneous hematoma presents more of an infiltrative pattern. The involved segment has no particular predilection for the duodenal area but may occur anywhere in the small or large bowel, often extending over a considerable length
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Fig. 4.-A young hemophiliac with a hematoma of the jejunum. “Thumbprinting” (arrow), as described with vascular occlusion, accompanies the picket fence pattern.
of gut. The affected loop is rigid and, at fluoroscopy, moves as a unit. The mucosal folds are thick and the troughs between them narrow, a pattern which persists throughout the examination. The normal feathery appearance of the mucosa is lost, as are the longitudinal folds, and the margins of the bowel show spikes of varying height (Fig. 3). Although quite similar in derivation to the coilspring of the traumatic cases, it has been likened to stacked coins by Khilnani et aL30 and to a picket fence by Wiot et al.‘O “Thumbprinting” or pseudotumor formation, as described by SchwartzK6 in connection with arterial occlusion, is also frequent (Fig. 4). However, the type of localized intramural mass seen in traumatic hematoma has not been encountered. Depending on the magnitude of the hemorrhage, the lumen may or may not be significantly narrowed. Extrinsic pressure on adjacent structures may result not only from hemorrhage in the bowel wall itself but also from blood within the adjacent mesentery.
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Fig. 5.-Specimen of small intestine which has been injected intramurally with water. The pattern resembles closely those seen in Figures 3 and 4. (Reproduced
with permission of Radiology.) If the cause of the spontaneous hemorrhage can be corrected, e.g. by discontinuing the drug in patients with anticoagulant intoxication, the roentgen picture gradually returns to normal over the next two or three weeks, DIFFERENTIAL
DIAGNOSIS
As previously stated, the combination of mass and coilspring pattern seen in traumatic hematoma is pathognomonic. The coilspring pattern of intussusception is accompanied by shortening of the intestine. This telescoping would be especially obvious in such a well defined segment as the duodenum. Many authorities suggest that the roentgen pattern of the nontraumatic form of hematoma is also diagnostic, and attempts have been made to distinguish one form of spontaneous bleeding from another by minor differences in the roentgen findings. I do not share these beliefs. The coilspring, stacked coin, or picket fence pattern produced by nontraumatic hematoma results from the relatively diffuse infiltration of a segment of the intestinal wall by liquid blood. In like manner, any other soft or fluid substance which diffusely infiltrates a segment of intestine may produce a similar if not identical pattern. Felson and Levin13r injected the wall of an isolated bariumfilled segment of small bowel with water. The resulting roentgenogram showed the “characteristic” pattern of spontaneous hematoma (Fig. 5). No localized mass was evident. Any condition causing relatively localized intramural thickening of the bowel, such as interloop abscess (Fig. 6) or pancreatitis (Fig. 7) or infarction (Fig. lo), is capable of producing the same appearance. Intestinal edema might also be expected to cause this pattern. Marshak and Lindner, elsewhere in this issue (Fig. 20), illustrate a patient with nephrosis in whom a mild form of the pattern with a more diffuse distribution is seen. FrimannDahPQ demonstrates a case of phlegmonous jejunitis and another with small bowel obstruction in which the picket fence appearance is well seen. Diffuse
Fig, I &--Small intestinal changes secondary to interloop abscess. (A) Rklptu lred (B) Tubovaria: n abscbess. aPPe” dix. Changes are most striking in left mid-abdomen. Note 1humbprinting. 226
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Fig. ‘I.-Changes
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in duodenojejunal
area in acute pancreatitis.
infiltration of a segment of gut wall by neoplastic cells (Fig. 8), or by soft structural abnormalities, such as lymphangiectasia ( Fig. 9) ,” under appropriate circumstances may produce similar changes. In none of these conditions, then, are the roentgen signs alone adequate for diagnosis. The clinical findings are often but not always decisive. Evidence of a bleeding tendency, a history of anticoagulant treatment, signs and laboratory evidence of pancreatitis, auricular fibrillation, etc.-all of these are inportant leads. Just to bring one of the problems into focus, the differentiation between mesenteric infarction and intramural hematoma is of obvious importance; yet, given an elderly cardiac patient with vascular disease who is receiving anticoagulant therapy and develops intestinal bleeding, abdom--“See also Fig. 18 in the article by Marshak
and Lindner,
elsewhere
in this issue.
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Fig. (P.-Three patie :nts with terminal ileum cha nges. What is your diag nosis? See legend of Fig ure 9 for answer.
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229
Fig. 9.-Changes resembling intramural hematoma but caused by lymphangiectasia. Answers to Fig. 8: (A) Mesenteric infarction. (B) Carcinoid. (C) Hematoma in a hemophiliac. inal pain, and even shock, does he have mesenteric infarction or intramural hematoma (Fig. lo)? The roentgen signs of the two are similar and, with either, a rapid return to a completely normal roentgen appearance may occur. But with mesenteric infarction, surgical intervention may be life-savintoxication it is life-threatening. While ing, while with anticoagulant Khilnani et al.“O pointed out certain subtle differences in the roentgen signs, with spasm, irritability, lack of a mesenteric mass and edema pointing towards mesenteric infarction, in my own experience these signs have seldom been of help. Despite these problems, the recognition of the stacked coin pattern is im-
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Fig. 10. (A) Cardiac patient on coumarin. Does he have mesenteric infarction or hematoma? (Fig. A is dated 6/24/63.) (B) Note return to normal after five days.
(C) Same patient four months later. Proved mesenteric artery occlusion. portant. Although the specific cause of the abnormality may be uncertain, established the nature of the pathologic process- intramural infiltration-is and limits the number of possibilities. Clinical features may then be utilized for differential diagnosis. SUMMARY
Intramural small intestinal hemorrhage has many causes but produces only two roentgenographic patterns. In one, the traumatic form, the pattern is
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diagnostic if all the manifestations are recognized. In the spontaneous form, however, the pattern is almost identical with the appearance of certain nonhemorrhagic conditions. Recognition of this stacked coin or picket fence appearance limits the diagnostic possibilities, and differentiation can usually be established by clinical and laboratory findings. ACKNOWLEDGMENTS The author expresses his sincere gratitude to Dr. Benjamin Felson for his suggestions and advice and to Mr. Jerry Chamberlin for his assistance. Thanks is also given to Dr. Harold Margolin for permission to use Figure 8C and to Dr. Stanley Nedehnan for Figure 10. REFERENCES 1. Barnes, C. G., and Duncan, G. W.: Anaphylactoid purpura simulating acute regional ileitis. Brit. J. Surg. 29: 253-255, 1941. 2. Beamish, It. E., and McCreath, N. D.: Intestinal obstruction complicating anticoagulant therapy. Lancet 2:390-392, 1961. 3. Bergman, B. J., and Crowson. C. N.: Intramural hematoma of the duodenum; report of a case with review of the literature. Med Serv. J. Canada 15:449-456, 1959. 4. Berman, H., and Mainella, F. S.: Toxic results of anticoagulant therapy. New York J. Med. 52:725-727, 1952. 5. Bertelsen, S.: Intramural hematoma of the duodenum. Acta Chir. Stand. 128: 556-563, 1964. 6. Brust, N. M.: Ileo-ileal intussusception associated with Henoch-Schonlein’s purpura; report of case with discussion. Arch. Pediat. 69:212-218, 1952. 7. Caird, D. hl., and Ellis, H.: Intramural haematoma of the duodenum. A report of a case and a review of the literature. Brit. J. Surg. 45:389-391, 1958. 8. Cooling, C. I.: Subserous duodenal hematoma. Brit. Med. J. 1:1051, 1953. 9. Culver, G. J., Pirson. H. S., Melch. E., Berman, L., and Abrantes, F. J.: Intramural hematoma of the jejunum. Radiology 76:785-789, 1961. 10. Culver, G. J., and Pirson, H. S.: Intramural hematoma of the duodenum. Amer. J. Roentgen. 82:1032-1035, 1959. 11. Culver, G. J., and Pirson, H. S.: Intramural hematoma of jejunum: case report. Amer. J. Roentgen. 90:732-734, 1963.
12. Davis, D. Il., and Thomas, C. Y.: Intramural hematoma of the duodenum and jejunum: a cause of high intestinal obstruction-Report of three cases due to trauma. Amer. Surg. 153:394398, 1961. 13. Dey, D. L.: Acute duodenal obstruction due to an intramural haematoma. Med. J. Australia 1:708, 1952: 14. Esposito, J. J.: Small intestinal abnormalities in anaphylactoid purpura. Radiology 55:548-552, 1950. 15. Felson, B., and Levin, E. J.: Intramural hematoma of the duodenum. Radiology 633823-831, 1954. 16. Ferguson, I. A., and Goade, W. J., Jr.: Intramural hematoma of the duodenum. New Eng. J. Med. 260:11761177, 1959. 17. Fetter, J. S., and Mills, W. L.: Roentgenographic findings in SchonleinHenoch’s purpura. Radiology 55:545547,195o. 18. Frieden, J. H., and Kaplan, L.: An intestinal complication of anticoagulant therapy. Calif. Med. 98:159-161, 1963. 19. Frimann-Dahl, J,: Roentgen Examinations In Acute Abdominal Diseases. Springfield, Ill., C. C Thomas, 1960. 20. Garfinkel, B., Waleson, M., and Furst, N. J.: Hematoma of the duodenum. Amer. J. Surg. 95:484486, 1958. 21. Gilbert. A. E., and Jorgenson, N. C.: Small bowel obstruction due to hemorrhage secondary to anticoagulant therapy. Amer. J. Surg. 99:945948. 1960. 22. Class, G. C.: Hemorrhage in a newly born infant, causing intestinal and biliary obstruction. Report of a case with necropsy. Amer. J. Dis. Child. 54:1052c1056, 1937.
232 23. Goldfarb, W. B.: Coumarin-induced intestinal obstruction. Ann. Surg. 161: 2734, 1965. 24. Golding, M. R., DeJong, P., and Parker, J. W.: Intramural hematoma of the duodenum. Ann. Surg. 157:573-578, 1963. 25. Gordon, W. B., Howell, J. F., and Gordon, J. R.: A rare cause of intestinal obstruction: traumatic intramural hematoma associated with leiomyoma of the jejunum. Report of a case. Arch. Surg. 78:556-569, 1959. 26. Izant, R. J.. Jr., et al.: Duodenal obstruction due to intramural hematom:! in children. J. Trauma 4:797-813. 1964. 27. Judd, D. R., Taybi, H., and King, H.: Intramural hematoma of the small bowel. Arch. Surg. 89:527-535, 1964. 28. Katz, A. M.: Hemorrhagic duodenitis in myocardial infarction. Ann. Intern. Med. 51:212-218, 1959. 29. Khautzjun, A. von: Darmstenose durch submucose Hamatome bei Hamaphilit. Arch. Klin. Chir. 87:542-551, 1908. 30. Khilnani, hf. T.. hfarshak, R. H., Eliasoph, J., and Wolf, B. S.: Intramural intestinal hemorrhage. Amer. J, Roentgen. 92: 1061-1071, 1964. 31. Kirkpatrick, W. E.: Submucosal hematoma of the duodenum: discussion and report of a case. Amer. J. Roentgen. 83:857-860, 1960. 32. Kramer. R. A.. et al.: Intramural small bowel bleeding during anticoagulant therapy. Arch. Intern. Med. 113:213217. 1964. 33. Lampert. E. (7.. Goodfellow. J. G., and Wachowski. T. J.: Traumatic subserosal hemorrhage causing small bowel obstruction. Ann. Surg. 140:768-770, 1954. 34. Liver&. K.: Hematoma of the jejunum with subileus. Acta Radiol. 30:163168. 1948. 33. Magladry. G. W.. Jr., and Mathewson. G., Jr.: Duodenal obstruction due to trauma. Stanford Med. Bull. 12:205206. 1954. 36. McClelland, J. R., Thistlethwaite, J. R., and Gerwig. W. H., Jr.: Obstruction of the distal duodenum due to intramural hemorrhage. Amer. Surg. 24:
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367-370, 1958. 37. McLaughlin, J.: False aneurysmal tumor occupying nearly whole of duodenum. Lancet 2:203-205. 1838. 38. McIntyre. J. A., and hlcIntyre, J. A.: Acute duodenal obstruction secondar! to hematoma. Canad. J. Surg. 5:324328. 1962. 39. Melamed. hI.. and Pantone. A. M.: Hematoma of the duodenum. Radiolog! 66:874-875. 1956. 40. h,festel. A. L.. et al.: Acute obstruction of small intestine secondary to hematoma in children. Arch. Surg. 78:2532. 1959. 41. hlirov. A. G.: Intramural hematoma of the dllodenum. Surgery 51:434-436. 1962. 42. Mood ._ E. E.: Acute jejunal obstruction secondary to traumatic intramural hematoma. Pediatrics 19:863-868. 1997. 43. hloore. S. W.. and Erlandson. hl. E.: Intramural hematoma of the duodenum. Ann. Sure;. 157:798-809, 1963. 44. Opnenheimer. G. D.: Acute obstruction of the duodenum due to submucous haematomn. Ann. Snrg. 98:192-196. 193.3. 45. Parrish. R. .4.: Intestinal obstruction: a complication of anticoagulant therapy. Amer. 1. Surg. 97:782. 1959. 46. Patton. T. B.: Duodenal injury due to trauma. nonpenetrating abdominal Amer. Surg. 23:587-593. 1957. 47. Pearson. S., and MacKenzie, R. J.: Intestinal obstruction due to bishydroxy coumarin (Dicumerol) poisoning. J. A. hf. A. 167:455-456. 1958. 48. Perry. E. C.. ancl Shaw. L. E.: On diseases of duodenum. Guy Hosp. Rep. 50: 1X-308. 1893. 49. Pester. G. H.. and Peartree, P.: Traumatic intramural hematoma of the duodenum. Amer. J. Surg. 96:568-570. 1958. 50. Platou. E. S.. and Platou. R. V.: Hemophilia with intestinal obstruction. hlinn. Med. 23:857. 1940. 51. Robarts. F. H.: Traumatic intramural hemntoma of proximal jejunal loop. A. M. i\. J. Dis. Child. 323484-487. 1957. 52. Robertson, C. W.. and Javett, S.: Small bowel obstruction due to spontaneous intramural hematoma: a rare complication of long term anticoagulant
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