sem informaçãoSpontaneous intramural duodenal hematoma is uncommon and is usually associated with coagulopathy, anticoagulant therapy and endoscopic procedures. The aim here was to describe a case of intramural duodenal hematoma caused by chronic exacerbation of pancre1366597601sem informaçãosem informaçãosem informaçã

Callejas, F.N.

Cazzo, E.

Chaim, E.A.

Esper, R.S.

Freire, L.M.D.

Ocariz, R.C.

Oliveira, J.H.B.

Sartori, F.S.

Sao Paulo Medical Journal

English

Repositorio da Producao Cientifica e Intelectual da Unicamp

UNIVERSIDADE ESTADUAL DE CAMPINAS
SISTEMA DE BIBLIOTECAS DA UNICAMP
REPOSITÓRIO DA PRODUÇÃO CIENTIFICA E INTELECTUAL DA UNICAMP
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http://www.scielo.br/scielo.php?script=sci_pdf&pid=S1516-31802017005018101
DOI: 10.1590/1516-3180.2017.0134290517
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©2018 by Associação Paulista de Medicina . All rights reserved.
DIRETORIA DE TRATAMENTO DA INFORMAÇÃO
Cidade Universitária Zeferino Vaz Barão Geraldo
CEP 13083-970 – Campinas SP
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      Sao Paulo Med J. 2018;136(6):597-601     597
CASE REPORTDOI: 10.1590/1516-3180.2017.0134290517
Intramural duodenal hematoma secondary to pancreatitis: 
case report and review of the literature
João Henrique Botto de OliveiraI, Raiza Samenica EsperI, Rodrigo Campos OcarizI, Flora Specian SartoriI, Lucas Marcelo Dias 
FreireII, Elinton Adami ChaimIII, Francisco Callejas-NetoIV, Everton CazzoV
Department of Surgery, Centro Médico de Campinas (CMC), Campinas (SP), Brazil
ABSTRACT
CONTEXT: Spontaneous intramural duodenal hematoma is uncommon and is usually associated with 
coagulopathy, anticoagulant therapy and endoscopic procedures. The aim here was to describe a case of 
intramural duodenal hematoma caused by chronic exacerbation of pancreatitis.
CASE REPORT: A 46-year-old male with chronic alcoholic pancreatitis was admitted to hospital due to 
abdominal pain, melena and low hemoglobin. An intramural duodenal hematoma with active bleeding 
was detected and selective angioembolization was warranted. The patient evolved with a perforated duo-
denum and underwent laparotomy with exclusion of the pylorus and Roux-en-Y gastrojejunostomy. He 
was discharged nine days later.
CONCLUSION: Intramural duodenal hematoma is a rare complication of pancreatitis. Selective emboliza-
tion is the preferred treatment for hemorrhagic complications of pancreatitis. However, the risk of visceral 
ischemia and perforation should be considered.
IMD. Resident Physician, Department of Surgery, 
Centro Médico de Campinas (CMC), Campinas 
(SP), Brazil
IIMD. Attending Physician, Endovascular Surgery 
Unit, Centro Médico de Campinas (CMC), 
Campinas (SP), Brazil
IIIMD, PhD. Full Professor, Department of Surgery, 
Faculdade de Ciências Médicas da Universidade 
Estadual de Campinas (FCM/UNICAMP), 
Campinas (SP), Brazil.
IVMD, MSc. Assistant Professor, Department of 
Surgery, Faculdade de Ciências Médicas da 
Universidade Estadual de Campinas (FCM/
UNICAMP), Campinas (SP), Brazil.
VMD, PhD. Adjunct Professor, Department of 
Surgery, Faculdade de Ciências Médicas da 
Universidade Estadual de Campinas (FCM/
UNICAMP), Campinas (SP), Brazil.
KEY WORDS: 
Pancreatitis. 
Duodenum. 
Hematoma.
Embolization, therapeutic.
Duodenal diseases. 
INTRODUCTION
The first description of an intramural duodenal hematoma was made by McLauchlan in 1838. 
This condition is usually associated with blunt abdominal trauma. Spontaneous intramural 
duodenal hematoma is uncommon and has been linked to coagulopathy, anticoagulant ther-
apy and endoscopic procedures.1-3 Other causes include several pancreatic diseases, colla-
genosis, peptic ulcers and pancreaticoduodenal aneurysm.4-7 To date, the exact mechanism 
leading to intramural hematoma in cases of pancreatitis has not yet been fully elucidated and 
the prognosis has not yet been completely defined, mainly due to its scarcity.1,3,5-9
This study sought to describe a case of an intramural duodenal hematoma caused by chronic 
exacerbation of pancreatitis.
CASE REPORT
The patient (JCAP) was a 43-year-old white male who had been a chronic abuser of alcohol for 
25 years (two liters of distilled liquor/day), with an antecedent of acute pancreatitis five years 
before the present case report. He had been complaining of strong typical pain for three days, 
along with melena. 
At admission to hospital, the following test results were noted: leukogram = 15,000 u/l, 
hemoglobin = 16 g/dl and amylase = 99 IU/l. A computed tomography (CT) scan showed signs 
of chronic pancreatitis and a bulky submucosal duodenal hematoma from the bulb to the third 
portion of the duodenum with intramural active bleeding in the region of the gastroduodenal 
artery (Figure 1A). Upper digestive tract endoscopy revealed a large submucosal hematoma in 
the duodenum, without any active bleeding into the lumen (Figure 2). 
On the following day, the hemoglobin level decreased to 12 g/dl and selective angioembo-
lization was indicated. During angiography, active bleeding was detected (Figure 3A). After 
embolization, no more signs of active bleeding were observed (Figure 3B). 
CASE REPORT | Oliveira JHB, Esper RS, Ocariz RC, Sartori FS, Freire LMD, Chaim EA, Callejas-Neto F, Cazzo E
598     Sao Paulo Med J. 2018;136(6):597-601
duodenal rupture from the bulb to the second portion of the duo-
denum, along with signs of acute pancreatitis. The duodenal rup-
ture was closed, along with exclusion of the pylorus, and Roux-
en-Y gastroenteroanastomosis was carried out. 
The patient then progressed with a high-output duodenal fis-
tula. Treatment consisting of parenteral nutrition, octreotide and 
antibiotic therapy was started, and this led to regression over a 
nine-day period. A control CT scan demonstrated regression of the 
hematoma, while the signs of chronic pancreatitis continued to be 
present, but without evidence of exacerbation (Figure 1C). A con-
trasted upper gastrointestinal radiographic series showed exclusion 
of the pylorus and patent gastroenteroanastomosis. The patient 
was then followed up for six months, with uneventful evolution.
DISCUSSION
Duodenal hematomas have been described as complications of 
both acute and chronic pancreatitis. Acute pancreatitis is a com-
mon disease, with an incidence of 20 to 40 cases/100,000 person-
years of life and a mortality rate close to 5%, and the vast majority 
of the cases are of biliary etiology.10 On the other hand, chronic 
pancreatitis is a progressive inflammatory disorder characterized 
by irreversible destruction of the pancreatic parenchyma and may 
Figure 2. Upper gastrointestinal endoscopy.
Figure 3. Arterial embolization: A) active bleeding in the region of the 
gastroduodenal artery; B) post-embolization control.
Table 1. Database search results for duodenal hematomas 
caused by pancreatitis
Electronic databases Search strategies Results
MEDLINE (PubMed)
(Duodenum) AND 
(Hematoma) AND 
(Pancreatitis)
13 case reports
LILACS (BVS)
(((Duodenum) OR 
(Duodeno)) AND 
(Hematoma) AND 
((Pancreatitis) OR 
(Pancreatite) OR 
(Pancreatítis)))
1 case report
Figure 1. Computed tomography scans: A) at admission; B) post-embolization; C) post-surgical control.
A B C
One day after this procedure, there was worsening of the 
pain. A CT scan showed signs of visceral perforation (Figure 1B). 
Emergency laparotomy was warranted and revealed the following: 
an ischemic duodenum with a bulky wall hematoma and a 6-cm 
A B
Intramural duodenal hematoma secondary to pancreatitis: case report and review of the literature | CASE REPORT
      Sao Paulo Med J. 2018;136(6):597-601     599
Author
Age 
(years)
Gender
Etiology of 
pancreatitis
Anticoagulant/
antiplatelet 
therapy or 
coagulopathy
Treatment Outcome
Bodnár et al.1 33 Male Hypertriglyceridemia No Conservative
Evolved with a pancreatic abscess 
that required CT-guided aspiration; 
no specific therapy for the duodenal 
hematoma; discharged after six weeks
Leundji et al.2 45 Male Alcoholic
Yes 
(thrombopenic 
due to portal 
hypertension)
Conservative Asymptomatic one year afterwards
Eurboonyanun 
et al.3
27 Male Alcoholic No Conservative Uneventful; discharged after 17 days
Dugernier 
et al.4
32 Male Biliary No Conservative
Evolved with infected necrosis 
that required repeated surgical 
debridement and drainage; no specific 
therapy for the duodenal hematoma 
was carried out due to the poor clinical 
condition; discharged after six months
Fukunaga 
et al.5
49 Male Alcoholic No
Surgical drainage and 
biopsy
Uneventful; discharged after 18 days
Neuzillet et al.6 62 Male Alcoholic No Pancreaticoduodenectomy Uneventful
Lee et al.7 47 Male Dengue fever
Yes (dengue 
hemorrhagic 
fever)
Conservative
Evolved with a peripancreatic abscess 
that required drainage 51 days after 
admission; uneventful evolution after 
drainage
Lee et al.8 55 Male Alcoholic No Endoscopic drainage
Uneventful after drainage; follow-up 
CT demonstrated a smaller intramural 
mass in the duodenum and upper 
endoscopy showed a small duodenal 
ulcer
Veloso et al.9 64 Male Unknown
Yes (aspirin and 
clopidogrel due 
to a previous 
myocardial 
infarction)
Conservative Uneventful; discharged after 14 days
Ma et al.12 32 Male Alcoholic No
Pancreaticoduodenectomy 
after failure of conservative 
therapy
Discharged two weeks after surgery; 
uneventful late postoperative 
evolution
Dubois et al.13 55 Male Alcoholic No Conservative Uneventful
Khurana et al.14 73 Female
Pancreatic 
malignancy
Yes (warfarin for 
deep venous 
thrombosis)
Conservative
Uneventful; after resolution of 
duodenal hematoma, the patient 
underwent distal pancreatic resection
Farhoud et al.15 71 Female Obstructive
Yes (warfarin for 
deep venous 
thrombosis)
Conservative Uneventful; discharged after 10 days
Fesenmeyer 
et al.16
71 Male Unknown No Conservative Uneventful
CT = computed tomography.
Table 2. Previously reported cases of intramural duodenal hematoma secondary to pancreatitis1-9,12-16
CASE REPORT | Oliveira JHB, Esper RS, Ocariz RC, Sartori FS, Freire LMD, Chaim EA, Callejas-Neto F, Cazzo E
600     Sao Paulo Med J. 2018;136(6):597-601
be associated with disabling chronic pain and permanent loss of 
exocrine and endocrine function. The majority of such cases are 
alcohol-related. Their prevalence is 3-4 cases/100,000 people.11
One of the rarest and most fatal complications of pancreatitis is 
spontaneous bleeding of intestinal vessels. A review of the literature 
was conducted through an online search for the MeSH terms “duo-
denum”, “hematoma” and “pancreatitis” in MEDLINE (via PubMed) 
and LILACS (via BVS) in papers published over the last 20 years 
(Table 1). We included original studies that reported single cases 
or case series of this disease. All the papers were checked according 
to their titles and abstracts (screening). Full papers were obtained 
from journals available through the website of the Commission 
for Improvement of Higher Education Personnel (Comissão de 
Aperfeiçoamento de Pessoal de Nível Superior, CAPES), of the 
Brazilian Ministry of Education. Articles that were unavailable 
were requested from their authors. Articles presenting potentially 
relevant studies were read and analyzed to assess the inclusion cri-
teria. We excluded articles that consisted of in vitro or animal stud-
ies, articles in which the participants’ characteristics did not match 
those mentioned above, poster session abstracts, review articles and 
other types of publications. Articles that described traumatic or 
iatrogenic duodenal hematomas were also excluded. Other papers 
were used for contextualization and discussion. 
After extensive online research, we identified 14 studies, which 
were all single case reports. Table 21-9,12-16 summarizes the main 
articles found and their reported outcomes. Figure 4 presents a 
flow diagram of the articles selected.
Vascular erosion occurs due to extravasation of proteolytic 
enzymes. Potentially fatal bleeding, characterized by a decrease of 
two hemoglobin points, are rare complications occurring in about 
1% to 5% of patients with acute or chronic pancreatitis. The vessels 
most affected are the gastroduodenal, pancreatoduodenal, splenic, 
gastroepiploic and left gastric arteries, because of their proximity to 
the pancreas, along with small branches of the inferior mesenteric 
arteries. The symptoms include pain, melena, hematemesis and ret-
roperitoneal bleeding. Upper endoscopy, CT scans and angiography 
are involved in making the diagnosis.17 
The majority of the previously reported cases showed that con-
servative therapy was possible, but this method is associated with 
lengthier hospital stay and a need for transfusion of blood components. 
Interventional therapies may include surgical repair using endoscopic 
and endovascular techniques. The benefits of endoscopy include its 
minimally invasive nature, compared with other treatment options, 
and the absence of radiation exposure. However, it has limitations, 
given that it cannot be used for areas of bleeding that are inaccessible 
to the intestinal lumen.8 Arterial embolization seems to be effective 
for management of bleeding. Embolization is considered successful 
when both radiologically and clinically there is evidence of bleeding 
control characterized by hemoglobin stabilization and absence of signs 
and symptoms of shock.18,19 Laparotomy for bleeding therapy should 
only be considered for hemodynamically unstable patients. Advances 
in endovascular radiology have led to this method becoming the pre-
ferred treatment option.18 
The present case demonstrates the need for a high degree of 
suspicion that the diagnosis could comprise bleeding caused by 
pancreatitis, as well as the need to remain open to the possibility 
of a severe and rare complication after embolization (visceral per-
foration). This complication requires rapid intervention, because 
the risk of mortality that it presents is up to 10 times greater than 
that commonly observed in cases of acute pancreatitis.20,21 The 
currently available evidence consists solely of single case reports, 
which thus precludes final conclusions regarding the optimal ther-
apy. Hence, further research is necessary.
CONCLUSION
Intramural duodenal hematoma is a rare complication of pancre-
atitis. Selective embolization is the preferred treatment, but the 
risk of visceral ischemia and perforation should be considered.
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Figure 4. Flow diagram of the narrative review of the literature.
Studies included  
in the review
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Full-text articles 
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Records excluded
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Reasons:
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Records screened
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Records excluded
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Reasons:
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Sources of funding: None 
Conflict of interest: None
Date of first submission: May 2, 2017 
Last received: May 2, 2017 
Accepted: May 29, 2017
Address for correspondence: 
Everton Cazzo 
Departamento de Cirurgia da Facudade de Ciências Médicas da 
Universidade Estadual de Campinas (FCM/UNICAMP) 
Rua Alexander Fleming, s/no  
Cidade Universitária Zeferino Vaz — Campinas (SP) — Brasil 
CEP 13085-000 
Tel. (+55 19) 3521-9450 
E-mail: notrevezzo@yahoo.com.br
© 2018 by Associação Paulista de Medicina 
This is an open access article distributed under the terms of the Creative Commons license.


Intramural duodenal hematoma secondary to pancreatitis: case report and review of the literature

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Intramural duodenal hematoma secondary to pancreatitis: case report and review of the literature

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