1. PATIENT PRESENTATION
A 59‐year‐old male with a past medical history of diabetes, hypertension, chronic kidney diseases, and coronary arterial diseases was transferred to our emergency department because of dull epigastric pain. He was under dual antiplatelet therapy with aspirin and ticlopidine. Upon arrival at the emergency deparment (ED), he presented with a pulse rate of 81 beats/min and a blood pressure of 147/66 mmHg. Physical examination revealed tympanic sounds on abdominal percussion and tenderness without muscle guarding over the epigastric area. Abdominal plain film showed a distended stomach (Figure 1), and gastrointestinal tract obstruction was suspected. Laboratory investigations showed an elevated lipase level (> 3000 U/L). A point‐of‐care ultrasound (POCUS) study revealed swelling of the pancreatic head and a heterogeneous lesion adjacent to the second portion of the duodenum (Figure 2 and Video S1). An urgent computed tomography scan was arranged and showed a heterogeneous hematoma over the patient's duodenum (Figure 3) and parenchymal enlargement of the pancreatic head.
FIGURE 1.
The posteroanterior erect view shows a distended stomach
FIGURE 2.
Abdominal ultrasound (panel A) shows a swelling pancreas head (P) and a heterogeneous lesion over the second and third parts of the duodenum (arrowhead). A heterogeneous lesion (H) over the third part of the duodenum is shown (panel B)
FIGURE 3.
A heterogeneous mass is noted over the duodenum (arrowhead), and parenchymal enlargement of the pancreatic head (arrow) is shown
2. DIAGNOSIS
2.1. Duodenal hematoma complicated by acute pancreatitis
Transarterial embolization of the gastroduodenal artery branch was performed promptly, and the bleeding was stopped. He was smoothly discharged 1 month later.
Duodenal hematoma often is associated with hematological disorders, anticoagulant or antiplatelet therapy, or malignancy. 1 Complications of duodenal hematoma range from occlusion of the duodenum, pancreatitis, acute cholecystitis, and bowel perforation to hemorrhagic shock. Intramural duodenal hemorrhage is an acute condition, and possible complications can be reduced by early diagnosis. 2 POCUS can aid significantly in locating an obstruction level and making a timely diagnosis. In addition, ultrasound is suitable for follow‐up changes in duodenal hematoma.
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Hsu C‐H, Kuo Y‐S, Chu S‐C, Lin C‐H. A man with epigastric pain. JACEP Open. 2021;2:e12535. 10.1002/emp2.12535
REFERENCES
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