Images in Emergency Medicine
Article Outline
A 9-year-old boy presented with abdominal pain and vomiting for 2 days. He had direct tenderness and guarding in the epigastric area. He had a history of contusion by bicycle handlebar 2 days previously. Abdominal radiography results were normal. Ultrasonography showed a heterogenous masslike lesion in the midabdomen (Figure 1). Computed tomography (CT) was performed to differentiate the cause of the abdominal mass (Figure 2).
Figure 1.
Ultrasonography showing a heterogenous mass containing a partially cystic portion.
Figure 2.
Axial (A) and coronal (B) images of contrast-enhanced abdomen CT showing about an 8.4-cm-×-4.5-cm-×-5.1-cm heterogenous attenuation density mass at the duodenal second and third portion. Used with permission of Sung Pil Chung, MD, PhD, Department of Emergency Medicine, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
Diagnosis
Duodenal hematoma
Duodenal hematoma is rare but mostly observed in children after blunt trauma.1 Duodenal hematoma and perforation are more frequent in the second and third segments, owing to the relative fixed position and the rich submucosal vascular supply of these segments.2
Symptoms and physical findings are nonspecific, with abdominal pain and bilious vomiting.2 Diagnostic difficulty may arise if the parent or child fails to disclose an episode of trauma that is regarded as an unrelated event.3 One third of patients become symptomatic more than 48 hours after injury because of increasing hematoma and obstruction.4
Ultrasonography showed a heterogenous mass containing a partially cystic portion. This finding suggests the possibility that the lesion could be a hematoma. Precontrast CT revealed a relatively high attenuation density. Contrast-enhanced CT showed that there was no change in the attenuation density of the same lesion, which suggested an acute hemorrhage. Additionally, contrast-enhanced CT might show associated lesions, such as active bleeding seen by extravasation of contrast material, parenchymal laceration, and perforation.
References
- . Intramural duodenal hematoma after blunt abdominal trauma. AJR Am J Roentgenol. 1998;170:38
- Sonographic diagnosis of intramural duodenal hematomas. J Clin Ultrasound. 1999;27:213–216
- . Traumatic duodenal haematoma in children. Injury. 1994;25:227–230
- Intramural hematoma of the duodenum. Arch Surg. 1988;123:54–58
For the diagnosis and teaching points, see page xx.
PII: S0196-0644(07)00723-8
doi:10.1016/j.annemergmed.2007.06.007
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
