Duodenal hematoma A case report of duodenal atresia following conservative management of a duodenal hematoma

In children, duodenal hematomas following blunt abdominal trauma are routinely treated conservatively. A case of a two-and-a-half-year-old female in whom conservative management was unsuccessful is presented. At surgery she was found to have an atretic duodenum secondary to the duodenal hematoma. Although uncommon, fibrotic stenosis must be considered in a patient who fails to show resolution of duodenal obstruction following conservative treatment for a duodenal hematoma.

B LUNT ABDOMINAL TRAUMA CAN lead to an intramural he matoma of the JuoJenal wall resulting in varying degrees of duodenal obstruction and intestinal ileus.The accepteJ treatment of a duodenal hematoma is nasogastric suc tion and, whe n indica ted, tcltal pa renteral nutrition.Most Juodenal hematomas reso lve spont aneously within the first seven to 10 days; however, there are isolated cases of duodenal obstruc tion taking up to 40 days to resolve ( l ).
A recent review reported that 73% of 62 pediatric case~ of duodenal hematomas were successfully treated with conservative management (2).Several of the rema ining c h ildren required operative intervention because of other intra-abdominal injuries.There were no missed perforntions or Juodena l strictures in either the surgical or conservati ve treatment groups.
To the authors' knowledge there are no reported cases of duodenal stenosis o r atresia seco ndary to du o dena l PASIEKA et al hematoma in the English literature.The following case is that of a young girl who presented with a duodenal hematoma secondary to chi ld abuse and went on ro develop stenosis and atresia of the duodenum over the course of conservative management.

CASE PRESENTATION
A previously well, two-and-a-halfyear-old female was seen in the emergency department with hair loss and bruising of the chest and abdomen.She was observed in the emergency department and sent home the same day.There was a suspicion of child abuse at that time but no evidence was gathered.Two weeks later she re-presented to the emergency department with abdom inal pain and bilious vomiting.On physical examination the patient was approximately 5% dehydrated and febrile.There was bruising on her back and over the epigastrium.The abdomen was diffusely tender with moderate rebound tenderness.Bowel sounds were absent.The remainder of the examination was unremarkable.Laboratory data revealed hemoglobin 127 g/L, white blood cell cbunt 23.8 g/L with 85% neutrophils, lipase 4 73 iu/L and amylase 289 iu/L.Electrolytes, prothrombin time and partial prothrombin time were all within normal limits.
Abdominal x-rays demonstrated a nonspecific gas pattern.Abdominal ultrasound revealed duodenal and pelvic hematomas.The pancreas appeared normal.
The patient was admitted to hospital with a diagnosis of duodenal hematoma and traumatic pancreatitis, thought to be secondary to nonaccidental trauma.She was treated with nothing by mouth and nasogastric suction, and resusc itated with intravenous fluids.Two days later she spiked a temperature of 39°C, hemoglobin had dropped to 89 g/L, and there was occu lt blood in her stools.At that time lipase was 1134 iu/L.The patient was started on total parenteral nutrition, ranitidine and triple antibiotic therapy (ampicillin, gen tam icin and metronidazole).Two days later, when the blood cultures were negative, the antibiotics were discontinued.A computed tomography of the 16  At this time the patient became jaundiced with a n e leva t ed bilirubin , a,partate a mino transfe rase, alkaline phosphata se, a nd ga mmag lucam y ltransferase, suggesting tota l pa ren teral nutrition -induced cho lestasis.A repeat upper gastro intestina l series on day 34 revealed a complete duodenal o bstruction (Figure 3), and a computed tomography scan demo nst ra ted a norm al pancreas wi th resolut ion o f the pelvic hematoma.Because of the fa ilure of conserva ti ve ma n age m e nt and th e development o f coral parenteral nutrition-induced c ho lescasis, the patie nt was surgically explo red.

SURGICAL FINDINGS
At laparocomy, there was ye llow staining of the perito neal cavity a nd a green tinge to the liver.The duodenum was dilated from the py lorus to the third portion, with a com plete atretic segment between the third and fo urth pa rts of the duod enum.] use beyond t he ligament of T rietz the re was a serosal tear in th e je junum , a nd the p ro xima l jejunum was dila ted.Further examination revealed a m e m b ra n e o n th e anterior wall of the p rox imal jejunum about 3 cm fro m the ligament ofT rie tz.Other than mild fa t n ecrosis aro und the head of che pancreas, there were no other intra-abdo mina l abno rmalities.A duodenocom y was pe rfo rmed whi ch confirmed an a tre cic segment at the junction o f the third and fo urth porti o ns o f the duode num.A n ente ros t o m y was m ad e in th e p ro xima l jejunum about 3 cm fro m the ligament o f Trietz.The m e m brane c aus ing stenosis of the jejunum was biopsied t0 rul e o ut a n eoplas m.This b io psy revealed hemo rrhage consistent with jejuna!hemato ma.The patient underwe nt a s id e-to-sid e d uodenojejunoscom y and closure o f the p rox ima l jejuna!e n terostom y.Pos to pe rati ve course was essen t ia lly unrem arka bl e. O n d ischarge the biliru bin, liver function tests, and pancreatic e nzymes had all returned co normal.

DISCUSSION
S ince the early 1970s, th e accepted t reatm ent of a diagn osed duo de na l hem acoma h as been conservati ve, with nasogastric suctio n and tota l pare nteral nutritio n.Prior to the advenL of conse rvative ma nagement, ma ny a utho rs advocated early operat ive interventio n Lo prevent d uodenal sten osis; ho wever, t he re are n o repo rted cases in th e liLeraturc of a d uoden al hema to ma causing stenosis o r atres ia.It has been postulated that the rich blood suppl y to the duod enum protects it fro m late stenosis (3 ).T he presen t case demo nstrates chat stenosis fo llo wing a duodena l hemaroma can occur and sho uld be considered in th e diffe rential d iagnos is of a patien t wh o d emo nstrates continuing o r inc reasing duod e nal obstructio n wi th conservati ve m an agemen t.
In the present case the duodena l injury was apparently severe eno ugh to cause significant vascula r comprom ise, res ul t ing in the develo pme n t of a fibrotic acretic segm en t of bowel.A ltho ugh there was evidence early in the co ur se o f m a n age m e nt ch at th e duod enal obstruction was not resolving, t h e pe rs iste n ce of sy mpto ms was t h o ught ro be re lated to o n go ing pa n creatitis a nd seconda ry infla mm atory duode na l o bstructio n .It became apparen t by the fi fth week, when clinical and biochemical evide nce of CAN J GAS111.0ENTEROL VOL 5 No l j ANUAR Y/FEBRUAR Y 199 1 Atresia following duodenal hematoma Figure 3 ) Upper gastrointestinal series on day 34 showing a disr.endedstomach and dilated duodenum 1vich complete obstruction of the rhird portion of the duodenum pan c rea t itis had resolved , t hat t he pat iem h aJ pers iste n t d uode n al obst ruct ion.
In summa ry, duodenal stenosis an J atre~ia may occur seco nda ry to a d uode na l h emacoma.Co nservative m anagemenL is t he treatment o f choice fo r a d uodenal hematoma.Ho wever, fa ilure of response or evidence of inc reasing bowel obstruc tion after several wee ks of conservaLi ve ma nageme nt, may necessita te laparoto my.

Figure
Figure I) Initial computed tomography scan demonstrating a duodenal hemawma with a normal appearing pancreas

Figure 2 )
Figure 2) Upper gastrointestinal series on day 10, showing a duodenal hematoma at the third part of the duodenum with flow disr.ally