Non-traumatic Intramural Duodenal Hematoma Secondary to Alcoholic Pancreatitis

Duodenal hematomas are a rare phenomenon, with the most common etiology being traumatic in origin. We describe the case of a spontaneous intramural duodenal hematoma in a 56-year-old male as a complication of alcohol-induced pancreatitis. Initial endoscopy showed evidence of a bulging deformity in the second and third parts of the duodenum. Further imaging using endoscopic ultrasound (EUS) demonstrated a round intramural cystic lesion in the third portion of the duodenum that was hypoechoic, septated, and measuring approximately 6.0 x 7.6 cm in diameter and yielded a bloody aspirate. A computed tomography angiography (CTA) of the abdomen and pelvis after aspiration depicted an intramural/periduodenal fluid collection with rim enhancement measuring 12.4 x 10.6 x 6.5cm extending from the proximal duodenum to the distal horizontal segment with possible breach of the inferior serosal wall. Upon attempt of oral intake, the patient's abdominal pain returned, and subsequent imaging revealed the intramural collection was larger compared to previous imaging. The patient was transferred to a tertiary facility in stable condition. Repeat imaging at the outside facility indicated a newly dilated common bile duct in addition to the intramural hematoma. An AXIOS stent placement (Boston Scientific, Marlborough, Massachusetts, US) was ultimately placed, and the patient was discharged home after three weeks on a clear liquid diet with total parental nutrition (TPN) supplementation. The patient subsequently developed duodenal stenosis secondary to ulceration, resulting in a gastric outlet obstruction, and ultimately underwent a robotic gastrojejunostomy for duodenal bypass eight months after initial presentation.