Duodenal Hematoma

1. Definition

Duodenal hematoma is a localized collection of blood within the duodenal wall (intramural) or immediately adjacent to it (extramural) that causes wall thickening and may compress the lumen. Iatrogenic duodenal hematoma refers to those resulting from endoscopic instrumentation or therapeutic procedures during esophagogastroduodenoscopy (EGD). Traumatic duodenal hematomas arise after blunt or penetrating abdominal trauma.

2. Epidemiology and Risk Factors

General epidemiology

• Duodenal hematoma is uncommon; robust incidence data are limited and most knowledge derives from case reports, small series, and trauma registries.
• After EGD the complication is rare, substantially less than 1% in contemporary series.
• In trauma, abdominal injuries occur in ~10%–15% of injured children and duodenal injuries are an uncommon but important subset with diagnostic challenges due to retroperitoneal location.

Key risk factors for iatrogenic (EGD-associated) hematoma

• Anticoagulant and antiplatelet therapy, especially combination therapy or inadequate periprocedural management
• Known coagulopathy or platelet dysfunction (congenital or acquired)
• Therapeutic endoscopic interventions (biopsy, polypectomy, dilation, injection, sclerotherapy)
• Forceful instrumentation, difficult duodenal intubation, scope looping
• Anatomic variations and postsurgical changes (strictures, diverticula, adhesions)
• Chronic kidney disease or liver disease causing platelet dysfunction
• Older age with vascular fragility

Trauma-specific risk factors

• Blunt mechanisms: motor vehicle collisions, falls, bicycle handlebar impacts (classic for duodenal and pancreatic injury)
• Deceleration injuries and crush mechanisms that shear bowel at fixed points (ligament of Treitz, ileocecal valve)
• Penetrating trauma: gunshot and stab wounds
• Nonaccidental trauma must be considered in young children or when history is inconsistent

3. Pathophysiology

Duodenal hematoma results from vascular disruption within the duodenal wall or adjacent mesentery. Mechanisms vary by cause:

• EGD-associated: direct mechanical trauma from the endoscope or accessories (biopsy forceps, snares, dilators, injection needles) injuring submucosal vessels; coagulopathy permits ongoing intramural bleeding and hematoma expansion.
• Blunt trauma: compressive force between an external object and the vertebral column, deceleration/shear at fixed points causing vessel rupture and intramural hemorrhage; handlebar impacts often produce focal duodenal wall injury.
• Penetrating trauma: direct perforation with intramural/extamural bleeding and associated mesenteric vascular injury.

Hematoma expansion causes luminal narrowing or obstruction, local ischemia and inflammation, and rarely transmural necrosis, secondary infection, pancreatitis, or biliary obstruction by mass effect.

4. Clinical Presentation

Symptoms vary by size, location, and whether obstruction, perforation, or active bleeding is present. Onset can be immediate or delayed hours to days after injury or procedure.

• Abdominal pain (epigastric or RUQ) — most common symptom
• Nausea and vomiting, often bilious when obstruction is distal to the ampulla
• Failure to tolerate oral intake, progressive abdominal distension
• Gastrointestinal bleeding (hematemesis, melena) if mucosal disruption occurs
• Palpable mass may be present in large hematomas
• Shock is uncommon but possible with brisk hemorrhage
• Pediatric-specific: irritability, feeding refusal, vomiting, signs of trauma; maintain suspicion for nonaccidental injury when history is inconsistent

5. Diagnostic Evaluation

Initial evaluation

• Primary survey and resuscitation per ATLS/PEM-ALS principles in trauma or unstable patients
• Obtain CBC, type and crossmatch if bleeding suspected, PT/INR, aPTT, platelet count, BMP, and consider serum amylase/lipase if pancreatitis suspected
• Early hematology consultation when coagulopathy is present or suspected

Imaging modalities and their roles

• Contrast-enhanced CT abdomen — preferred modality in hemodynamically stable adults and older children; defines intramural hematoma, extent, lumen compression, active extravasation, associated injuries, free fluid, mesenteric vascular injury
• Abdominal ultrasound — radiation-sparing initial test in children; can detect bowel-wall thickening or echogenic intramural collections but is operator dependent and less sensitive than CT
• Upper GI contrast study (barium or water-soluble) — demonstrates luminal obstruction, “coiled spring” or “thumbprinting” sign for intramural hematoma and helps follow resolution; limited for extraluminal injuries
• Plain radiographs — low sensitivity but can show free air, fractures, or radiopaque foreign bodies; lateral decubitus preferred acutely over upright films
• FAST — good for rapid detection of intraperitoneal fluid but low specificity for bowel injury and variable sensitivity in pediatrics
• Diagnostic laparoscopy — useful for assessment and possible therapy in stable trauma patients when imaging is equivocal
• Repeat EGD — generally avoided acutely because instrumentation may exacerbate a hematoma; reserved for therapeutic indications after correction of coagulopathy and by experienced endoscopists

CT findings suggestive of duodenal or bowel injury

• Intramural high-attenuation collection or focal bowel wall thickening with luminal narrowing
• Moderate to large free fluid without solid organ injury (raises suspicion for bowel injury)
• Extraluminal gas or oral contrast extravasation (specific for perforation)
• Mesenteric fat stranding, mesenteric fluid, mesenteric vessel cutoff or beading (suggests vascular/mesenteric injury)
• Portal venous gas or mesenteric venous gas (indicates mucosal disruption)

6. Management

Management is guided by hemodynamic status, presence of ongoing bleeding, perforation, degree of obstruction, and associated injuries. Most duodenal hematomas without perforation or uncontrolled hemorrhage are managed conservatively.

Conservative (first-line for stable patients)

• NPO and bowel rest
• Nasogastric decompression for significant vomiting or obstructive symptoms
• IV fluids, electrolyte repletion, analgesia, antiemetics; avoid NSAIDs
• Correction of coagulopathy: stop anticoagulants; reverse warfarin with vitamin K and PCC when indicated; reverse heparin with protamine; use DOAC reversal agents when appropriate; platelet transfusion for severe thrombocytopenia; targeted factor replacement as needed; involve hematology early
• Close monitoring: serial abdominal exams, vitals, serial hemoglobin/hematocrit, coagulation testing
• Nutritional support: consider enteral feeding distal to obstruction (nasojejunal) or TPN when prolonged NPO anticipated
• Expected course: symptomatic improvement often begins within days; radiographic resolution commonly over 1–3 weeks though individual variability exists

Endoscopic, radiologic, and surgical interventions

• Endoscopic hemostasis — reserved for accessible active luminal bleeding after correction of coagulopathy; endoscopic drainage of hematoma is rarely indicated and high risk
• Angiography with embolization — indicated when angiography identifies an arterial bleeding source amenable to embolization or when less invasive control is required in unstable bleeding
• Surgery — indicated for perforation, peritonitis, ongoing uncontrollable hemorrhage, ischemia, or persistent obstruction with nonresolution; options include evacuation, primary repair, resection with or without diversion, bypass procedures, and drainage
• Multidisciplinary coordination — engage gastroenterology, interventional radiology, surgery, and hematology early for moderate-to-severe or complicated cases

7. Clinical Course and Complications

Typical course

Most patients with intramural duodenal hematoma managed conservatively improve clinically within days, with radiographic resolution over 1–3 weeks. Diet advancement should follow clinical and imaging improvement.

Potential complications

• Persistent duodenal obstruction requiring intervention
• Perforation and peritonitis
• Infection/abscess formation within the hematoma
• Secondary pancreatitis from compression of the pancreatic duct
• Biliary obstruction from compression of the distal biliary tree
• Pseudoaneurysm formation or delayed arterial bleeding
• Duodenal-cutaneous fistula after surgical repair (noted postoperative complication)

Prognosis

Overall prognosis is favorable with timely recognition and appropriate management. Mortality is rare and typically associated with delayed diagnosis, massive hemorrhage, uncontrolled sepsis, or multisystem trauma.

8. Pediatric Considerations

• In children blunt trauma (handlebar, MVC) is the most common cause of duodenal hematoma; iatrogenic cases from endoscopy are rarer but important when coagulopathy exists.
• Always consider nonaccidental trauma (child abuse) when history is inconsistent with injuries or in very young children.
• Use ultrasound as an initial imaging modality when appropriate to minimize radiation; apply CT dose-reduction protocols when CT is required.
• Children dehydrate more quickly; monitor fluid status closely and use weight-based dosing for all medications and blood products.
• Pediatric hematology involvement is essential if a bleeding disorder is discovered or suspected.
• Surgical intervention is less common in children for hematoma alone; most resolve with conservative measures, but multidisciplinary discussion is recommended early if deterioration occurs.

9. Duodenal Injury Classification (Simplified)

10. Prevention and Periprocedural Recommendations

• Preprocedure screening: identify bleeding history, medications (anticoagulants/antiplatelets), and coagulopathy; obtain baseline coagulation tests when indicated
• Antithrombotic management: individualize holding, bridging, or continuation of anticoagulants and antiplatelet agents per guideline-based assessment of thrombotic versus bleeding risk in consultation with cardiology/hematology when necessary
• Endoscopic technique: use gentle atraumatic duodenal intubation, appropriate instrument sizing, minimize deep biopsies in friable tissue and plan therapeutic maneuvers carefully with hemostatic tools available
• Postprocedure monitoring: observe high-risk patients longer and provide clear return precautions for abdominal pain, vomiting, or bleeding
• Documentation: record indication, devices used, any difficulties or immediate complications to inform future care

11. Practical Clinical Checklists

Checklist — Suspected Post-EGD or Post-traumatic Duodenal Hematoma

Checklist — Trauma Evaluation for Small Bowel/Duodenal Injury

12. Key Practical Takeaways

• Duodenal hematoma may be iatrogenic after EGD or traumatic; clinical and imaging features overlap and initial conservative care is often successful when there is no perforation or uncontrolled bleeding.
• Contrast-enhanced CT is the diagnostic study of choice in stable patients; ultrasound is valuable as an initial, radiation-sparing tool in children.
• Correct coagulopathy promptly and avoid unnecessary repeat endoscopy in the acute phase; involve hematology early when abnormal coagulation is present.
• Maintain high suspicion for nonaccidental trauma in pediatric patients with unexplained abdominal injuries.
• Escalate to interventional radiology or surgery for ongoing bleeding, perforation, ischemia, or failure of conservative management.