Abstract
Jejunal intramural hematoma (JIH) is rare. A 5-year-old girl, a known attention-deficit hyperactivity disorder child with paraneoplastic symptoms, on imaging showed a suspicion of Jejunal intramural mass with internal bleeding. Laparotomy showed a JIH. Evacuation of hematoma and Histopathological Examination (HPE) ruled out tumor. Possible explanation of the manifestation is suggested.
KEYWORDS: Attention-deficit hyperactivity disorder, blunt abdominal trauma, child, hollow viscus injury, jejunal hematoma
INTRODUCTION
Jejunal hematoma (JH) is rare and can be a part of duodeno jejunal hematoma.[1] An attention-deficit hyperactivity disorder (ADHD) girl child with paraneoplastic symptoms showed a suspicion of jejunal intramural mass (JIM) with internal bleeding on imaging. Laparotomy ruled out tumor and jejunal intramural hematoma (JIH) was evacuated.
CASE REPORT
A 5-year-old girl with ADHD was admitted for abdominal pain, nonbilious vomiting, episodes of watery stools, bradycardia, and fluctuations of blood pressure. There was no history of trauma, child abuse, melena, or bleeding diathesis. No mass was felt. Blood investigations did not reveal blood dyscrasias. Electrocardiogram and echocardiogram were normal. Pain X-ray abdomen was normal initially but later showed dilated bowel loops and soft tissue shadow of a mass in the left hypochondrium [Figure 1a and b]. Ultrasound revealed a poorly defined mural lesion in the proximal gut in the left hypochondrium [Figure 1c] and d]. Contrast computed tomography (CT) abdomen showed an intramural mass of proximal jejunum with internal bleeding [Figure 2a and b]. Due to increasing anemia, onset of obstruction and suspicion of JIM with internal bleeding, laparotomy was done to rule out functioning GI tumor. A subserosal and intermuscular JH of about 10 cm in the proximal jejunum starting From duodenojejunal junction was found [Figure 2c]. The serosa got torn while delivering the mass and hematoma was evacuated. There was no pathological lesion [Figure 2d]. Bradycardia and unstable blood pressure became normal once the hematoma was evacuated. Serosa was closed with interrupted stitches. Peroperative findings and HPE confirmed the diagnosis to be JIH. The child is symptom free for the past 2 years.
Figure 1.
(a) Plain X-ray abdomen was normal during initial period of hospitalization. (b) Subsequent plain X-ray abdomen showed dilated bowel loops and soft tissue shadow of a mass in the left hypochondrium. (c and d) Ultrasound showed a poorly defined segmental mural lesion in the proximal gut in the left hypochondrium
Figure 2.
(a and b) Contrast computed tomography abdomen showed an intramural extra mucosal polypoid mass of proximal jejunum with internal bleeding in the coronal and longitudinal scans. (c) Circumferential jejunal hematoma of about 10 cm in length from the duodenojejunal junction. (d) Subserosal and intermuscular cavity after the evacuation of hematoma
DISCUSSION
JH occurs due to the relative fixed position of duodenojejunal junction by ligament of Treitz to the rest of the mobile proximal jejunum. JH can also be due to blood dyscrasias, Henoch-Schonlein purpura, child abuse, endoscopic biopsy, or anticoagulation.[1,2,3,4] Only a few cases have been reported since the first description by Liverud in1948.[1] JH may resolve or may progress to obstruction, intussusception, perforation, and bleeding or may develop complications of other associated injuries. Pain X-ray abdomen is nonspecific.[3] Contrast GI study, ultrasound, CT scan, and MRI (Magnetic Resonance Imaging) show pathognomonic “Spring coil” appearance of JH.[1,3,4] The management options are (1) conservative management alone for cases related to blood dyscrasias and cases without concomitant intraabdominal injuries,[3,4] (2) initial conservative management failing which surgery,[3,4] (3) laparotomy and proceed is for JH with peritonitis and concomitant intraabdominal Injuries,[4] and (4) Laparotomy and simple surgical evaluation of hematoma. This method has almost become the treatment of choice now.[2,3,4] Hemangioma and tumors of the intestine can mimic intramural hematoma in the absence of classic diagnostic features.[5] In this case, functioning tumor with bleeding and obstruction was suspected. Laparotomy and HPE ruled out a tumor and final diagnosis of JIH was made. The cause of the hematoma could be due to unrecognized trauma or child abuse in an ADHD girl. As we could not find the cause of paraneoplastic symptoms, we assume that they were probably due to the mass effect over the autonomic nerves which have an anatomical proximity to the duodenojejunal junction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We thank Dr. Sundaram Balasubramanian, MD and HOD Pediatrics, Kanchi Kamakoti CHILDS Trust Hospital for referring the child to the Pediatric Surgery department for the surgical department.
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