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Traumatic intramural hematoma of the duodenum
Traumatic
Intramural Hematoma Duodenum
of the
GEORGE H. PESTER, M.D. AND PATRICK PEARTREE, M.D., Council Blu$s, From tbe Jennie Edmundson Memorial Hospital, Council Bluffs, Iowa.
of periodic paroxysma abdomina1 pain. The parents had not noted any bright bIood or oId blood in the vomitus. There had been no bowe1 movement for two days. PhysicaI examination reveaIed no abnormalities except for marked dehydration and the abdomina1 findings. There were no marks of injury. The abdomen was moderateIy distended and there was tenderness in the epigastrium. Fiat and upright fdms of the abdomen were essentiaIIy normaI. The patient was given a small amount of barium by mouth and the stomach was noted to be markedIy diIated and to extend into the peIvis. (Fig. I.) The stomach contained a Iarge amount of fluid. No barium couId be expressed beyond the duodena1 bulb. A Levin tube was inserted into the stomach and the patient was given parentera ffuids to correct the dehydration. Nasogastric suction was continued overnight. The gastric drainage contained “coffee ground” materiaI and biIe. After the stomach was emptied, the patient stated that he was comfortabIe. PhysicaI examination of the abdomen on the foIlowing day was entireIy normal. The abdomen was scaphoid; there were no areas of tenderness and no masses were paIpable. On March 7th, after twenty-four hours of gastric suction, upper gastrointestinal examination with barium reveaIed aImost compIete obstruction of the second portion of the duodenum. The esophagus, stomach and duodenal buIb were normal. Definite narrowing was noted, with anterior dispIacement of the second portion of the duodenum by an extrinsic mass. At the four-hour examination there was marked retention of barium in the stomach, and onIy a smaII portion of the barium had passed into the Iower smal1 boweI. A diagnosis of intramural hematoma of the second portion of the duodenum was made. The area of obstruction of the duodenum had the typica “coiIed spring” appearance reported by FeIson and Levin. (Fig. 2.) On March 8th, with the patient under general anesthesia, the abdomen was opened through a high right transverse incision. There was no free
XTRAVASATIONof bIood into the submucosa1 or subserosa1 Iayers may produce partia1 or compIete obstruction of the duodenum. In 1933 Oppenheimer [I] was the first to report two cases; one a compIication of extensive neopIastic invasion of the duodenum, and the other from a ruptured aneurysm. In 1952 Dey [2] reported one case with no history of injury or known bIood dyscrasia. The first case of intramura1 hematoma of the duodenum caused by injury was reported by Stirk [j] in 1953. Additiona cases caused by injury incIude one by MagIadry and Mathewson [4] in 1954, four by Felson and Levin [T] in 1954, one by Snider [6] in 1956, and one by Watanabe and Inouye [7] in 1956. On study of the upper gastrointestina1 tract with barium, FeIson and Levin [5] noted that the obstructed area of the duodenum had a characteristic “coiIed spring” appearance. This finding was present in their four cases and they considered it to be an important diagnostic roentgen sign. Snider reported a simiIar finding in his patient. Since this condition has been recognized onIy recentIy as a distinct entity, we beIieved that our case shouId be reported and the treatment discussed.
E
CASE REPORT The patient, a ten year oId white boy, was admitted to the Jennie Edmundson HospitaI on March 6, 1957. On March 3rd, whiIe pIaying basketbaII, he feIl on some wire and a portion of a cement bIock. He complained immediately of sharp pain in the abdomen but ten minutes Iater returned to pIay basketbalI. Three hours after the injury he refused to eat his evening mea1 and four hours after the injury he vomited and continued to vomit to the time of hospital admission. He aIso compIained American Journal
of Surgery,
Volume 96, October, 1938
Idwa
568
Hematoma
of Duodenum
FIG. 2. Examination twenty-four hours later :rftcr nasogastric suction. The “coiled spring” effect 01 the proxima1 duodenum was more obvious :rt flu~~roscopy and on spot fiIms than on this reproduction. Note anterior disphtcement and narrowing of dista1 desccnding arm of the duodenum, the site of the hem:rtom:~.
FIG. I. Upper gastrointestinal series on the day of admission. The stomach is markedly dilated and fiIIrd with fluid; no barium passed through the duodenum. tluid or blood within the peritoneal cavity. The abdominal viscera were essentially normaI with the exception of the duodenum. There was an ovoid mass approximateIy 6 by 4 by 4 cm. involving the later-oposterior wall of the second portion of the duodenum. The mass had the appearance of a hematoma. It was incised with a short Iongitudinal incision placed Iaterally, and approximately 60 cc. of old dark blood and a few smaI1 clots were evacuated from the submucosal area. This completely decompressed the mass. Incidental appendectomy was performed. The abdomen was closed with a Pemose drain inserted down to the foramen of WinsIow and brought through a stab wound placed below the abdominal incision. The postoperative period was uneventfu1. The patient was started on a progressive diet. The drain and the sutures were removed on the fifth postoperative day; there was no drainage from the stab wound. Upper gastrointestinal studies made on the fifth postoperative day were essentiaIIy normal. (Fig. 3.) The patient was dismissed the same day. Upper gastrointestinal studies repeated four weeks later were aIso normal. At that time the patient was feeling well and was eating a usua1 diet without difficulty.
Blood studies, including platelet count, bleeding time, coagulation time and clot retraction time, were normal. COMMENTS
X-ray studies of the abdomen in this particuIar case of trauma were diagnostic. After ruling out the possibility of a ruptured viscus by clinicaI examination and by ffat and upright rorntgenograms of the abdomen, the patient was given a smaI1 amount of barium by mouth. This examination revealed compIete obstruction of the outIet of the stomach. After proIonged aspiration of the stomach, barium studies on the folIowing day reveaIed the typical of an intramural “ coiIed spring ” appearance hematoma in the descending duodenum. IncompIete obstruction of the duodenum from an intramural hematoma may be treated successfuIIy by watchfu1 waiting. One case reported by Felson and Levin 151was so treated. 569
Pester and Peartree opinion that drainage of the hematoma wouId provide Iess morbidity. The remainder of the reported cases were treated by surgical evacuation of the hematoma, with or without gastroenterostomy. If the obstruction is reIieved by evacuation of the hematoma, a more extensive procedure is unnecessary. If doubt exists that the obstruction cannot be reIieved, a short-circuiting gastroenterostomy wouId be indicated. SimpIe drainage of the hematoma in this case Ied to a rapid and compIete recovery. REFERENCES I. OPPENHEIMER, G. D. Acute
obstruction of the duodenum due to submucous haematoma. Ann. Surg., 98: 192-196, 1933. 2. DEY, D. L. Acute duodena1 obstruction due to an intramura1 haematoma. M. J. Australia, I: 708, 1952. 3. STIRK, D. I. A case of subserous duodena1 haematoma. &it. M. J., I: 712, 1953. 4. MAGLADRY, G. W., JR. and MATHEWSON, C., JR. Duodenal obstruction due to trauma. Stanford M. Bull.. 12: 205-206, 1954. 5. FELSON, B. and LEVIN, E. J. IntramuraI hematoma of the duodenum; a diagnostic roentgen sign. Radiology, 63 : 823-83 I, I gob. 6. SNIDER, H. R. Acute duodena1 obstruction secondary to intramural hematoma. Surgery, 39: 860-864,
FIG. 3. Re-examination five days after surgica1 evacuation of the intramura1 hematoma.
1956. 7. WATANABE, L. M. and INOUYE, M. R. DuodenaI obstruction due to intramural hematoma: review of the literature and report of a case. Calijorornia Med., 85: 254-256, 1956.
Snider [6] expIored the abdomen of his patient but did not evacuate the hematoma because of incompIete obstruction. However, he was of the
570
Intramural Hematoma Duodenum
of the
GEORGE H. PESTER, M.D. AND PATRICK PEARTREE, M.D., Council Blu$s, From tbe Jennie Edmundson Memorial Hospital, Council Bluffs, Iowa.
of periodic paroxysma abdomina1 pain. The parents had not noted any bright bIood or oId blood in the vomitus. There had been no bowe1 movement for two days. PhysicaI examination reveaIed no abnormalities except for marked dehydration and the abdomina1 findings. There were no marks of injury. The abdomen was moderateIy distended and there was tenderness in the epigastrium. Fiat and upright fdms of the abdomen were essentiaIIy normaI. The patient was given a small amount of barium by mouth and the stomach was noted to be markedIy diIated and to extend into the peIvis. (Fig. I.) The stomach contained a Iarge amount of fluid. No barium couId be expressed beyond the duodena1 bulb. A Levin tube was inserted into the stomach and the patient was given parentera ffuids to correct the dehydration. Nasogastric suction was continued overnight. The gastric drainage contained “coffee ground” materiaI and biIe. After the stomach was emptied, the patient stated that he was comfortabIe. PhysicaI examination of the abdomen on the foIlowing day was entireIy normal. The abdomen was scaphoid; there were no areas of tenderness and no masses were paIpable. On March 7th, after twenty-four hours of gastric suction, upper gastrointestinal examination with barium reveaIed aImost compIete obstruction of the second portion of the duodenum. The esophagus, stomach and duodenal buIb were normal. Definite narrowing was noted, with anterior dispIacement of the second portion of the duodenum by an extrinsic mass. At the four-hour examination there was marked retention of barium in the stomach, and onIy a smaII portion of the barium had passed into the Iower smal1 boweI. A diagnosis of intramural hematoma of the second portion of the duodenum was made. The area of obstruction of the duodenum had the typica “coiIed spring” appearance reported by FeIson and Levin. (Fig. 2.) On March 8th, with the patient under general anesthesia, the abdomen was opened through a high right transverse incision. There was no free
XTRAVASATIONof bIood into the submucosa1 or subserosa1 Iayers may produce partia1 or compIete obstruction of the duodenum. In 1933 Oppenheimer [I] was the first to report two cases; one a compIication of extensive neopIastic invasion of the duodenum, and the other from a ruptured aneurysm. In 1952 Dey [2] reported one case with no history of injury or known bIood dyscrasia. The first case of intramura1 hematoma of the duodenum caused by injury was reported by Stirk [j] in 1953. Additiona cases caused by injury incIude one by MagIadry and Mathewson [4] in 1954, four by Felson and Levin [T] in 1954, one by Snider [6] in 1956, and one by Watanabe and Inouye [7] in 1956. On study of the upper gastrointestina1 tract with barium, FeIson and Levin [5] noted that the obstructed area of the duodenum had a characteristic “coiIed spring” appearance. This finding was present in their four cases and they considered it to be an important diagnostic roentgen sign. Snider reported a simiIar finding in his patient. Since this condition has been recognized onIy recentIy as a distinct entity, we beIieved that our case shouId be reported and the treatment discussed.
E
CASE REPORT The patient, a ten year oId white boy, was admitted to the Jennie Edmundson HospitaI on March 6, 1957. On March 3rd, whiIe pIaying basketbaII, he feIl on some wire and a portion of a cement bIock. He complained immediately of sharp pain in the abdomen but ten minutes Iater returned to pIay basketbalI. Three hours after the injury he refused to eat his evening mea1 and four hours after the injury he vomited and continued to vomit to the time of hospital admission. He aIso compIained American Journal
of Surgery,
Volume 96, October, 1938
Idwa
568
Hematoma
of Duodenum
FIG. 2. Examination twenty-four hours later :rftcr nasogastric suction. The “coiled spring” effect 01 the proxima1 duodenum was more obvious :rt flu~~roscopy and on spot fiIms than on this reproduction. Note anterior disphtcement and narrowing of dista1 desccnding arm of the duodenum, the site of the hem:rtom:~.
FIG. I. Upper gastrointestinal series on the day of admission. The stomach is markedly dilated and fiIIrd with fluid; no barium passed through the duodenum. tluid or blood within the peritoneal cavity. The abdominal viscera were essentially normaI with the exception of the duodenum. There was an ovoid mass approximateIy 6 by 4 by 4 cm. involving the later-oposterior wall of the second portion of the duodenum. The mass had the appearance of a hematoma. It was incised with a short Iongitudinal incision placed Iaterally, and approximately 60 cc. of old dark blood and a few smaI1 clots were evacuated from the submucosal area. This completely decompressed the mass. Incidental appendectomy was performed. The abdomen was closed with a Pemose drain inserted down to the foramen of WinsIow and brought through a stab wound placed below the abdominal incision. The postoperative period was uneventfu1. The patient was started on a progressive diet. The drain and the sutures were removed on the fifth postoperative day; there was no drainage from the stab wound. Upper gastrointestinal studies made on the fifth postoperative day were essentiaIIy normal. (Fig. 3.) The patient was dismissed the same day. Upper gastrointestinal studies repeated four weeks later were aIso normal. At that time the patient was feeling well and was eating a usua1 diet without difficulty.
Blood studies, including platelet count, bleeding time, coagulation time and clot retraction time, were normal. COMMENTS
X-ray studies of the abdomen in this particuIar case of trauma were diagnostic. After ruling out the possibility of a ruptured viscus by clinicaI examination and by ffat and upright rorntgenograms of the abdomen, the patient was given a smaI1 amount of barium by mouth. This examination revealed compIete obstruction of the outIet of the stomach. After proIonged aspiration of the stomach, barium studies on the folIowing day reveaIed the typical of an intramural “ coiIed spring ” appearance hematoma in the descending duodenum. IncompIete obstruction of the duodenum from an intramural hematoma may be treated successfuIIy by watchfu1 waiting. One case reported by Felson and Levin 151was so treated. 569
Pester and Peartree opinion that drainage of the hematoma wouId provide Iess morbidity. The remainder of the reported cases were treated by surgical evacuation of the hematoma, with or without gastroenterostomy. If the obstruction is reIieved by evacuation of the hematoma, a more extensive procedure is unnecessary. If doubt exists that the obstruction cannot be reIieved, a short-circuiting gastroenterostomy wouId be indicated. SimpIe drainage of the hematoma in this case Ied to a rapid and compIete recovery. REFERENCES I. OPPENHEIMER, G. D. Acute
obstruction of the duodenum due to submucous haematoma. Ann. Surg., 98: 192-196, 1933. 2. DEY, D. L. Acute duodena1 obstruction due to an intramura1 haematoma. M. J. Australia, I: 708, 1952. 3. STIRK, D. I. A case of subserous duodena1 haematoma. &it. M. J., I: 712, 1953. 4. MAGLADRY, G. W., JR. and MATHEWSON, C., JR. Duodenal obstruction due to trauma. Stanford M. Bull.. 12: 205-206, 1954. 5. FELSON, B. and LEVIN, E. J. IntramuraI hematoma of the duodenum; a diagnostic roentgen sign. Radiology, 63 : 823-83 I, I gob. 6. SNIDER, H. R. Acute duodena1 obstruction secondary to intramural hematoma. Surgery, 39: 860-864,
FIG. 3. Re-examination five days after surgica1 evacuation of the intramura1 hematoma.
1956. 7. WATANABE, L. M. and INOUYE, M. R. DuodenaI obstruction due to intramural hematoma: review of the literature and report of a case. Calijorornia Med., 85: 254-256, 1956.
Snider [6] expIored the abdomen of his patient but did not evacuate the hematoma because of incompIete obstruction. However, he was of the
570