Wake Forest University School of Medicine Winston-Salem, North Carolina
Introduction: Spontaneous duodenal wall hematomas are rare but well reported complications of pancreatitis. Patients can present with symptoms of small bowel obstruction and should initially be managed conservatively. Arterial embolization and laparoscopic drainage of the hematoma may be needed in patients who do not improve with supportive care.
Case Description/Methods: A 48-year-old male with a history of alcohol dependence and excessive non-steroidal anti-inflammatory drugs (NSAIDs) use presented with a one-month history of abdominal pain, nausea, and vomiting. The patient denied recent trauma or anticoagulant use. Two weeks prior, a computed tomography (CT) scan showed pancreatic head stranding and serum lipase was 172. Outpatient conservative management was planned but patient presented with worsening obstructive gastroenterology (GI) symptoms requiring a nasogastric tube. On examination, his temperature was 99.5, heart rate 112 and moderate diffuse abdominal tenderness was noted, greatest in the epigastric area. On labs, his lipase was 185. A CT abdomen showed a large descending duodenal wall hematoma with partial proximal obstruction and pancreatic head inflammatory changes related to pancreatitis. EGD showed collapsed 2nd portion of duodenum, without any mucosal lesion. The obstructive GI symptoms continued to worsen, and CT angiography showed enlarging duodenal wall hematoma, so evacuation was planned. In anticipation of evacuation, interventional radiology embolized the gastroduodenal and inferior pancreaticoduodenal artery to prevent further expansion of the hematoma followed by a laparoscopic drainage of the hematoma by surgery. Post-procedure, the patient’s obstructive symptoms resolved.
Discussion: Blunt trauma, bleeding disorders, anticoagulant therapy, and iatrogenic factors are all potential causes of duodenal hematoma; however, our patient denied all these potential explanations. There have been multiple reports discussing how spontaneous duodenal hematomas may be a rare complication of pancreatitis. The mechanism is still unclear but it may be related to the release of proteolytic enzymes from an inflamed pancreas or ectopic pancreas, causing vascular erosions in the small bowel. Management includes supportive care with fluid resuscitation, pain control and NG decompression. A laparoscopic drainage of the hematoma may be required if hematoma is expanding with worsening obstructive symptoms and a prophylactic arterial embolization may help drainage by stabilizing the bleeding.
