© Georg Thieme Verlag KG Stuttgart · New York
Intramural duodenal hematoma as a complication of pancreatic cancer
18 April 2007 (online)
Intramural duodenal hematoma (IDH) occurs mainly in children, secondarily to blunt abdominal injury. In adults, blunt abdominal trauma accounts for 70 % of IDH cases . Nontraumatic causes of IDH in adults include coagulation disorders, duodenal biopsy, and endoscopic injection therapy for bleeding ulcers . Very few cases of IDH of pancreatic origin have been reported   . We describe a case of IDH presenting as a complication of pancreatic cancer. This report highlights the need to consider a malignant process as a possible etiology of IDH.
A 70-year-old man was admitted to hospital with coffee ground emesis and epigastralgia. There was no history of alcohol use, anticoagulant therapy, nonsteroidal anti-inflammatory drug (NSAID) use, or recent abdominal trauma. On esophagogastroduodenoscopy, multiple distal esophageal ulcers and a volcanic ulcerative mass in the duodenal bulb, which had a significantly narrowed lumen, were noted (Figure ). Biopsy specimens of the mass consisted of duodenal mucosal tissue with ulceration that was infiltrated by inflammatory cells but not tumor cells. Abdominal computed tomography demonstrated a heterogeneous, hyperdense mass located in the right anterior pararenal space and a low-attenuation mass in the uncinate process of the pancreas (Figure ). A diagnosis of an intramural duodenal hematoma secondary to the pancreatic mass was made.
Figure 1 Endoscopic view of the duodenal bulb shows a volcanic ulcerative mass that almost completely obstructs the lumen.
Figure 2 Unenhanced abdominal computed tomography scan shows a heterogeneous, hyperdense mass in the right anterior pararenal space adjacent to the duodenum (arrowheads). A low-attenuation mass is shown in the uncinate process of the pancreas (arrow).
The patient underwent a Whipple procedure. An ovoid tumor, measuring 3 × 3 × 2.8 cm, was located in the uncinate process of the pancreas (Figure ). The duodenum was gray, fleshy, and soft, with an 8 × 5 × 1.8 cm hemorrhagic cystic lesion within the duodenal wall, which was in contact with the margin of the pancreatic tumor (Figure ). On microscopy, moderately differentiated ductal adenocarcinoma of the uncinate process of the pancreas, with invasion to the duodenal submucosa, was seen. Postoperatively, the patient recovered uneventfully and was discharged after 15 days.
Figure 3 Gross appearance of the resected specimen. a The hematoma is visible within the wall of the duodenum (arrows), and an ovoid tumor is present in the uncinate process of the pancreas (arrowheads). b The tumor is seen invading to the wall of the duodenum (arrow).
- 1 Jewett Jr T C , Caldarola V, Karp M P. et al . Intramural hematoma of the duodenum. Arch Surg. 1988; 123 54-58
- 2 Rohrer B, Schreiner J, Lehnert P. et al . Gastrointestinal intramural hematoma, a complication of endoscopic injection methods for bleeding peptic ulcers: a case series. Endoscopy. 1994; 26 617-621
- 3 Fesenmyer M E, Nelson D B. Intramural duodenal hematoma due to pancreatitis. J Clin Gastroenterol. 1998; 26 350-352
- 4 Bellens L, Van Hee R, Vanderstighelen Y, Vanderputte S. Intramural duodenal hematoma of pancreatic origin. Hepatogastroenterology. 1999; 46 930-932
- 5 Van Spreeuwel J P, van Gorp L H, Bast T J, Nadorp J H. Intramural hematoma of the duodenum in a patient with chronic pancreatitis. Endoscopy. 1981; 13 246-248
C.-A. Tseng, MD
Division of Gastroenterology
Department of Internal Medicine
Buddhist Dalin Tzu Chi General Hospital
2 Min-Sheng Road, Dalin, Chia-Yi