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.1,2Sonography 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.
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.6,8Blunt 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
All pictures extracted from http://cai.md.chula.ac.th/lesson/atlas/T/page1t.html
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.8Sonography 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
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.
© 2004 by the American Institute of Ultrasound in Medicine