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by the American Institute of Ultrasound in Medicine J Ultrasound Med 23:1679-1683 • 0278-4297
Sonographic Diagnosis and Monitoring of an Obstructing Duodenal Hematoma After Blunt TraumaCorrelation With Computed Tomographic and Surgical FindingsFirst Department of Radiology (S.M., N.S., A.A., E.S.), Department of Computed Tomography (G.G., K.P., L.T.), and First Department of Surgery (N.K., M.M.), Venizelio General Hospital, Heraklion, Crete, Greece. Address correspondence and reprint requests to Stylianos Megremis, MD, PhD, 23 Arsinois St, 71303 Heraklion, Crete, Greece. E-mail: efstel{at}med.uoc.gr.
Abbreviations: BAT, blunt abdominal trauma • CT, computed tomography • DH, duodenal hematoma • GI, gastrointestinal • IVC, inferior vena cava
A traumatic duodenal hematoma (DH) is an unusual event, occurring mainly in children and young individuals, with a male predominance in both age groups. Furthermore, it can be a diagnostic challenge because of unreliable history, nonspecific signs and symptoms, delayed appearance, and the duodenum’s retroperitoneal location.1,2 Sonography is considered a reliable screening tool for blunt abdominal trauma (BAT)3,4; however, since the beginning of the last decade, only a small number of reported DH cases5–8 have been described by sonography. We illustrate the sonographic findings at the diagnosis and follow-up of a traumatic DH in a young man who was treated expectantly. We also present the sonographic findings of the resulted complete obstruction of the upper gastrointestinal (GI) tract and the DH’s postoperative sonographic appearance.
A 39-year-old man had progressively increasing abdominal pain, nausea, and vomiting. He reported that he had had a farming accident 30 hours before while he had been driving his tractor. Vital signs and laboratory test results were normal, except mild leukocytosis (11.0 x 103 white blood cells/µL). There was no history of hematologic disorders of anticoagulation therapy. Plain radiographs showed a distended stomach without evidence of perforation.
An abdominal sonogram obtained with an HDI 5000 scanner (Philips Medical Systems, Bothell, WA) and a C5-2 transducer revealed a complex oval mass with a maximal diameter of 6.5 cm in the expected location of the duodenum. It was partially liquefied, containing debris and a few thin septations (Figure 1A
Abdominal computed tomography (CT) to rule out perforation confirmed the initial diagnosis (Figures 1C  and 2C), and conservative treatment was decided. On the fourth day of admission, the patient continued to vomit, and another sonogram showed the known DH to have become more cystic and septate, increasing in size, with its longest diameter reaching 7.6 cm (Figure 3A ). The duodenal canal was narrowed with a tail-like end (Figure 3B). The stomach was distended (Figure 3C).
Because of persistent vomiting and the concern for an organizing seroma with the potential risk of rupture, the patient was taken to the operating room. At surgery, an intramural hematoma at the posteromedial aspect of the third part of the duodenum, together with multiple mesenteric contusions, was detected. One hundred twenty milliliters of hemorrhagic fluid were aspirated, but without successful complete DH evacuation (Figure 4 ). The duodenal lumen remained obstructed; a Tieman tube inserted at the adjoining healthy duodenal wall showed no patency. After that, a duodenal diversion with gastroenteroanastomosis was performed.
On the 10th postoperative day, another sonographic examination clearly showed the DH reduced in size and without a fluid component (Figure 5 ). After 16 days of hospitalization, the patient was discharged in a very good clinical condition.
Accurate diagnosis is essential for proper treatment of a DH. The clinical appearance and findings including abdominal pain, vomiting, tenderness, and a palpable mass can be nonspecific, accompanied by unremarkable laboratory test results.6,8 Blunt abdominal trauma, sometimes minor, is the leading cause of DHs, which occur in approximately four fifths of patients.9,10 Bleeding disorders, Henoch-Schönlein purpura, anticoagulation therapy, alcoholism, pancreatitis, tumors, duodenal ulcers, and local or iatrogenic factors are other implicative causes.7,10–13 Most hematomas resolve spontaneously without permanent changes. Treatment may be surgical or conservative using nasogastric suction and adequate parenteral nutrition. Expectant treatment of an isolated DH is generally preferred. Failure of conservative treatment is considered when there is no evidence of partial resolution after 5 days or complete resolution after 10 days or in cases of perforation, indicating surgical treatment.14 An upper GI series was for many years the only diagnostic tool for DHs before the advent of CT, which has been established as the examination of choice for duodenal injuries, especially in disclosing complications such as perforation and abscesses.15 However, CT was found to be diagnostic in 60% of patients with duodenal perforation.1 Various sonographic patterns have been described in DHs: (1) a duodenal wall thickening with hypoechogenicity16; (2) a duodenum-related mass of variable echogenicity, depending on the age of the hematoma7; and (3) a prevertebral cystic lesion simulating a pancreatic pseudocyst.6 This variability may reflect the difficulty in distinguishing the origin of small retroperitoneal lesions proximal to the bowel wall in the upper abdomen because of the enteric gas component and also the different characteristics of a hematoma depending on its age. Color-coded imaging has been shown to be helpful in differentiating a spontaneous DH from an intestinal mass.8 Sonography may be the first examination performed in a patient with epigastric abdominal pain or a palpable abdominal mass,8 and it is useful to be familiar with this uncommon entity. In BAT, sonography can additionally show associated lesions, including pancreatic traumatic pseudocysts and parenchymal lacerations, or a small amount of ascites caused by peritoneal blood or pancreatic fluid.17 Our case illustrates the sonographic evolution of a traumatic DH and its effects on the upper GI tract. The precise sonographic depiction of the lesion and the excellent definition of the anatomic landmarks may contribute, together with close clinical observation, to appropriate treatment. In conclusion, sonography may play a primary role, both in the diagnosis and the monitoring of DHs, when conservative treatment is attempted. Computed tomography may be reserved for inconclusive cases.
Received July 2, 2004, from the First Department of Radiology (S.M., N.S., A.A., E.S.), Department of Computed Tomography (G.G., K.P., L.T.), and First Department of Surgery (N.K., M.M.), Venizelio General Hospital, Heraklion, Crete, Greece. Revision requested July 21, 2004. Revised manuscript accepted for publication August 10, 2004.
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