Intraduodenal hematoma (IDH) is a rare cause of proximal bowel obstruction. Traumatic injury is the most common identifiable cause [1]. Risk factors for spontaneous non-traumatic small bowel hematomas include pancreatitis, bleeding disorders, anticoagulant therapy, vasculitis and bleeding diathesis [2] [3] [4]. We report an unusual case of small bowel obstruction, obstructive jaundice, and pancreatitis caused by a spontaneous IDH in a hemophiliac patient.

A 24-year-old male with history of hemophilia a presented with abrupt onset of severe epigastric pain, nausea, and coffee ground emesis. He had been non-compliant with his factor VIII infusion and endorsed recent heavy weight lifting. There was no history of direct trauma. On examination, the patient's vitals were within normal limits. He had hypoactive bowel sounds and tenderness in his epigastric region with no rebound or guarding. The rest of his physical examination was unremarkable. His initial laboratory workup revealed hemoglobin 8.1 g/dL, AST 13 u/L, ALT 10 u/L, alkaline phosphatase of 45 u/L, total bilirubin 0.6 mg/dL, and lipase level was of 1322 mg/dL. A computed tomography (CT) scan of the abdomen revealed an intraduodenal mass measuring 8.1x14x14 cm (Figure 1) extending into the intraperitoneal and retroperitoneal spaces with decompression of the distal small bowel loops and abutting the head of the pancreas. The mass measured 40 HU on the Hounsfield scale which is consistent with a hematoma. A more radiopaque mass in the center with 60 HU reflects a central blood clot. The patient was admitted to the intensive care unit for supportive care. A nasogastric tube was placed for decompression and packed red blood cells were transfused in addition to factor VIII (Humate P®) infusion.

On the third day of admission, after the patient was hemodynamically stable, an EGD revealed a Mallory Weiss tear near the cardia and a large hematoma in the lumen of the duodenum. The patient continued to be managed conservatively. On hospital day seven, the patient was noticed to have new onset jaundice, laboratory revealed a total bilirubin of 6.6 mg/dL (direct bilirubin was 5.0 mg/dL), AST 33 u/L and ALT 42 u/L. Computed tomography (CT) scan of the abdomen showed biliary and pancreatic duct dilation which was likely secondary to external compression from the duodenal hematoma. With further conservative management and factor VIII infusions, jaundice resolved with reduction of the hematoma on serial CT scans.

Intramural duodenal hematoma (IDH) is a rare cause of obstruction of the proximal gastrointestinal tract. Blunt abdominal trauma is the most common cause of IDH, a finding that has been attributed to the duodenum's relatively fixed location and its rich blood supply [1]. While anticoagulation with warfarin is the most common risk factor for spontaneous non-traumatic intramural bleeding, other causes of non-traumatic IDH include endoscopic biopsies, aneurysms, pancreatitis and bleeding diathesis [2] [3] [4].

IDH was first described in 1838 by Mclachan in a patient with pseudoaneurysm [5]. In 1908, Van Khautz reported the first case of spontaneous intramural hematoma in a hemophiliac patient [6]. Whereas traumatic small bowel hematomas commonly happen in the duodenum, most spontaneous hematomas tend to involve the jejunum [7][8]. Our patient had no risk factors which could explain why the bleeding occurred in the duodenum rather than the jejunum. Even though pancreatitis can lead to an intraluminal bleeding, it is very unlikely that pancreatitis can cause such a large hematoma. The clinical presentation of IDH is mostly abdominal pain. Subsequent vomiting may indicate that the hematoma becomes obstructive. Presence of jaundice should raise the suspicion of external compression of the biliary tree, but could also result from hematoma breakdown. Diagnosis of IDH relies largely on clinical suspicion and radiographic studies. The CT scan with contrast is the most useful diagnostic tool in detection of intraluminal hematomas. Hounsfield units scoring system is a quantitative scale used to describe radiodensity and gives a clue about the nature of the structures on CT scans. Freely flowing blood has a density of 20–45 Hounsfield units (HU), while blood clots are more radiopaque and generally score between 45 and 70 HU [9]. Magnetic resonance imaging (MRI) scan is a good alternative when the enhanced CT scan is not possible, typically showing the characteristic three-layered sign, which is caused by the tendency of hemosiderin to deposit into layers [10]. In hemodynamically stable patients with IDH, the management is usually conservative, which includes bowel rest, bowel decompression, and correction of coagulopathy. Resolution of the hematoma is usually expected within a few weeks which depends on the size of the hematoma [8]. Surgical intervention through laparoscopy or laparotomy is reserved for hemodynamically unstable patients or in cases of perforation or ischemia.

Spontaneous intraduodenal hematomas are one of the rare causes of intestinal obstruction and pancreatitis in a non-traumatic patients. High index of suspicion is required in patients with bleeding tendency who present with symptoms suggestive of high intestinal obstruction or pancreatitis.

1. Weil BR, Howard TJ, Zyromski NJ. Spontaneous duodenal hematoma: A rare cause of upper gastrointestinal tract obstruction. Arch Surg 2008 Aug;143(8):794–6.   [CrossRef]   [Pubmed]    
2. Veldt BJ, Haringsma J, Florijn KW, Kuipers EJ. Coumarin-induced intramural hematoma of the duodenum: Case report and review of the literature. Scand J Gastroenterol 2011 Mar;46(3):376–9.   [CrossRef]   [Pubmed]    
3. Hoenisch K, Prommegger R, Schwaighofer H, et al. Intramural duodenal hematoma after upper gastrointestinal endoscopy. Wien Med Wochenschr 2011 Sep;161(17-18):441–4.   [CrossRef]   [Pubmed]    
4. Ma JK, Ng KK, Poon RT, Fan ST. Pancreatic-induced intramural duodenal haematoma. Asian J Surg 2008 Apr;31(2):83–6.   [CrossRef]   [Pubmed]    
5. McLachlan J. Fatal false aneurismal tumor occupying nearly the whole of the duodenum. Lancet 1838;2:203–5.    
6. Von Khautz A. Darmstenose durch submucöse Hämatome bei Hämophilie. Arch Klin Chir 1908;87:542–1.    
7. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR Am J Roentgenol 2002 Dec;179(6):1389–4.   [CrossRef]   [Pubmed]    
8. Eichele DD, Ross M, Tang P, Hutchins GF, Mailliard M. Spontaneous intramural duodenal hematoma in type 2B von Willebrand disease. World J Gastroenterol 2013 Nov 7;19(41):7205–8.   [CrossRef]   [Pubmed]    
9. Kunnin JR, Korobkin M, Ellis JH, Francis IR, Kane NM, Siegel SE. Duodenal injuries caused by blunt abdominal trauma: Value of CT in differentiating perforation from hematoma. AJR Am J Roentgenol 1993 Jun;160(6):1221–3.   [CrossRef]   [Pubmed]    
10. Hahn PF, Stork DD, Vici LG, Femucci JT Jr. Duodenal hematoma: The ring sign in MR imaging. Radiology 1986 May;159(2):379–82.   [CrossRef]   [Pubmed]