Teaching Case

A 52-year-old male patient with history of chronic liver disease due to alcohol abuse presented with vomiting, abdominal pain and distension for the past 5 days. He also reported a 9-month history of epigastralgia and 25 kg weight loss.

An abdominal CT (Fig. 1) revealed a duodenal haematoma causing intestinal obstruction and haemoperitoneum in the anterior pararenal space, paracolic gutters and pelvis. No signs of active bleeding or malignant lesions were found. Inflammatory changes in the head of pancreas, few calcifications and dilatation of the pancreatic duct suggested chronic pancreatitis.

Follow-up CT at 1 week (Fig. 2) showed evolution of duodenal haematoma.

Three-month follow-up CT (Fig. 3) showed complete resolution of duodenal haematoma. There was thickening of the duodenal wall associated with millimetric cysts and inflammatory changes on the pancreaticoduodenal groove, suggestive of paraduodenal pancreatitis.

Echoendoscopy confirmed the presence of intramural cysts in the duodenum (no images available). MRI (Fig. 4) showed cystic formations within the duodenal wall of the inner part of 2nd and 3rd portions and a band of low-intensity signal on T2 and gadolinium enhancement in the pancreaticoduodenal groove.

Paraduodenal pancreatitis is a rare complication of heterotopic pancreas involving the groove between the head of the pancreas, the duodenum and the common bile duct [1]. Histologically it is characterised by the presence of cysts in the duodenal wall originated from enlarged ducts of ectopic pancreatic tissue and surrounded by inflammation and fibrosis [2].

Most patients are middle-aged men (up to 88% according to some series [2]) with a history of alcohol abuse and chronic pancreatitis. It can cause abdominal pain, vomiting, weight loss and jaundice due to duodenal or biliary stenosis [2].

Biliopancreatice coendoscopy is the exploration of choice to search for this entity. 
MRI of the biliary and pancreatic regions is a useful non-invasive diagnostic technique as it helps visualising cystic formations within the duodenal wall and a band of low-intensity signal on T1 and T2 sequences lying between the 2nd portion of the duodenum and the pancreas corresponding to heterotopic pancreatic tissue [3]. CT scan enables an evaluation of pancreatic lesions, but its diagnostic sensitivity is poorer. 

Therapeutic options include medical management with octreotide, endoscopic fenestration of bigger cysts and pancreaticoduodenectomy [3].

Intramural duodenal haematoma may occur as a result of blunt abdominal trauma or associated with pancreatitis, as happened in our patient. It can also occur spontaneously in anticoagulated patients or as a complication of endoscopic biopsy [4].

Written informed patient consent for publication has been obtained.