A Delayed Complication of Intramural Duodenal Hematoma: Severe Duodenitis Presenting With Gastrointestinal Bleeding

CASE REPORT A 59-year-old man with coronary artery disease and recent exploratory laparotomy for adhesive small bowel obstruction developed an intramural duodenal hematoma (IDH) identified on postoperative computed tomography after presenting with abdominal pain and obstruction (Figure 1). He improved with nasogastric decompression and intravenous proton pump inhibitor therapy and was discharged. Two weeks later, he represented with hematochezia and severe anemia (hemoglobin 4.9 g/dL). Computed tomography angiography demonstrated resolution of the hematoma without active bleeding (Figure 2). Esophagogastroduodenoscopy revealed diffuse severe erosive duodenitis with friability, shallow ulcerations, and a focal red spot suspected to be the bleeding source (Figure 3). Biopsies confirmed acute inflammatory mucosal injury. He was managed with transfusion and high-dose proton pump inhibitor therapy, with no recurrent bleeding.Figure 1.: Axial contrast computed tomography of the abdomen shows a large intramural hematoma involving the second portion of the duodenum (arrow), measuring approximately 5.7 cm in maximal diameter, with associated luminal narrowing and mass effect on adjacent structures.Figure 2.: Axial contrast computed tomography of the abdomen shows interval resolution of previously seen intramural duodenal hematoma (arrow) and no evidence of active gastrointestinal bleed.Figure 3.: (A) Esophagogastroduodenoscopy showing circumferential inflammation and edematous, granulated duodenal mucosa without active hemorrhage, consistent with severe inflammatory injury. (B) Additional endoscopic view demonstrating erosive duodenitis with mucosal erythema, friability, and shallow ulcerations in the second portion of the duodenum. A focal erythematous red spot (arrow) is noted and suspected to represent the source of bleeding.Intramural duodenal hematomas are uncommon and typically arise from trauma, anticoagulation, iatrogenic injury, or coagulopathy, most often involving the second portion of the duodenum due to its fixed retroperitoneal position and rich vascular supply.1,2 IDHs are often managed conservatively, but when symptomatic, patients commonly present with gastrointestinal obstruction, abdominal pain, or pancreatitis.3 This case highlights that delayed duodenitis and gastrointestinal bleeding can occur weeks after apparent resolution of IDH, even in the absence of other risk factors, representing a rare and likely underrecognized complication. DISCLOSURES Author contributions: Conceptualization and supervision: O. Brijawi. Data collection: All authors. Drafting of the manuscript: All authors. Critical review of the manuscript: All authors. Approval of the final version of the manuscript: All authors. O. Brijawi is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.