A Rare Case of Gastric Outlet Obstruction: Pancreatitis-induced Intramural Duodenal Hematoma: 1037

Introduction: Intramural duodenal hematoma (IDH) was first reported in 1838 by James McLaughlin during an autopsy of a patient who died of dehydration, duodenal obstruction; he noted at the time “a false aneurismal tumor occupying nearly the whole of the duodenum.” The majority of cases (70-75%) occur in the setting of blunt abdominal trauma, frequently in children. Other cases have occurred in patients who are susceptible to spontaneous bleeding such as those with hemophilia, von Willebrand disease or on anticoagulants. In extremely rare cases IDH has been associated with acute pancreatitis. IDH can lead to severe complications including small bowel obstruction, duodenal perforation, intussusception and bowel ischemia. Management of IDH ranges from conservative management (intravenous fluid and gastric decompression) to surgical evacuation. Case Report: A 54-year-old male with a history of alcohol abuse, Barrett's esophagus, and recurrent pancreatitis presented to the ED with abdominal pain radiating to the back, >50 episodes of emesis, and anorexia for 3 days. Physical exam was significant for epigastric tenderness. Abnormal labs included elevated lipase (250 IU/L), leukocytosis (14), and BUN/Cr acutely elevated (37/2.6). At esophagogastroduodenoscopy there was a large amount (1.5L) of gastric fluid in the esophagus and stomach. Examination of the duodenal bulb revealed a large extramural spherical mass causing almost complete duodenal obstruction. A duodenal hematoma was confirmed on subsequent CT imaging with areas of increased attenuation along the right, inferior aspects of the first, second, third portions of the duodenum; gastric distension, peri-pancreatic fluid were also noted. A nasogastric tube was placed for gastric decompression and fluids were administered intravenously. Repeat esophagogastroduodenoscopy performed 10 days later showed near total resolution of the hematoma. Discussion: Our patient presents as a rare, unusual case of IDH given his age, absence of abdominal trauma and with normal coagulation. Two suggested mechanisms of pancreatitis-induced IDH include 1) leakage of pancreatic secretions causing vascular injury to the anterior/posterior pancreaticoduodenal arcades inducing necrosis, hematoma formation, and 2) acute inflammation, hematoma formation developing from ectopic pancreatic tissue within the duodenal wall. Though surgical evacuation of the hematoma due to concern for duodenal perforation or persistent bowel obstruction has been advocated previously, conservative management with gastric decompression and IV fluids was successful in this case; the patient was able to resume clear liquids before TPN was initiated.