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plication assessment. Gastroenterology 1997;112: 1087–1095.
5.Ng CC, Hung FC, Hsieh CS, et al. Epidermolysis bullosa letalis with pyloric atresia in an infant. J Formos Med Assoc 1996;95:61–65.
6.Guadagni S, Gola P, Marsili L, et al. Arterial vasculature of the stomach and oncologic gastrectomies. [Review] Surg Radiol Anat 1995;17:269–276.
7.Hsu PI, Lai KH, Tseng HH, et al. Impact of Helicobacter pylori eradication on the development of MALT, gland atrophy and intestinal metaplasia of the antrum. Chin Med J 2000;63:279–287.
8.Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated Sidney system. Am J Surg Pathol 1996;20:1161–1181.
9.Bender GN, Peller T, Tsuchida A, Kelley JL. Double contrast upper gastrointestinal barium examination with biopsy versus endoscopy with biopsy in dyspeptic patients. Invest Radiol 1995;30:329–333.
10.Loffeld RJ. Diagnostic value of endoscopic signs of gastritis: with special emphasis to nodular antritis. Neth J Med 1999;54:96–100.
11.Chapman PR, Boals JR. Pneumopericardium caused by giant gastric ulcer. AJR 1998;171:1669–1670.
12.D’Inca R, Sturniolo G, Cassaro M, et al. Prevalence of upper gastrointestinal lesions and Helicobacter pylori infection in Crohn’s disease. Dig Dis Sci 1998;43: 988–992.
13.Sanguino JC, Rodrigues B, Baptista A, Quina M. Focal lesion of African histoplasmosis presenting as a malignant gastric ulcer. Hepatogastroenterology 1996;43: 771–775.
14.Radhi J, Kamouna M, Nyssen J. Phlegmonous gastritis following coronary bypass surgery. Can J Gastroenterol 1999;13:837–839.
15.Millward SF, Fortier M. Transient gastric emphysema caused by colonic infarction. AJR 2001;176:1331–1332.
16.Greaney TV, Nolan N, Malone DE. Multiple gastric polyps in familial amyloid polyneuropathy. Abdom Imaging 1999;24:220–222.
17.Joko T, Tanaka H, Hirakata H, et al. Phlegmonous gastritis in a haemodialysis patient with secondary amyloidosis. Nephrol Dial Transplant 1999;14:196–198.
18.Papa A, Cammarota G, Tursi A, et al. Histologic types and surveillance of gastric polyps: a seven year clinicopathological study. Hepatogastroenterology 1998;45: 579–582.
19.Cherukuri R, Levine MS, Furth EE, Rubesin SE, Laufer I. Giant hyperplastic polyps in the stomach: radiographic findings in seven patients. AJR 2000;175: 1445–1448.
20.Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Gastric inflammatory fibroid polyps: endoscopic ultrasonographic analysis in comparison with the histology. Gastrointest Endosc 1997;46:53–57.
21.Cho JS, Shin KS, Kwon ST, et al. Heterotopic pancreas in the stomach: CT findings. Radiology 2000;217: 139–144.
22.Park SH, Han JK, Choi BI, et al. Heterotopic pancreas of the stomach: CT findings correlated with pathologic findings in six patients. Abdom Imaging 2000;25: 119–123.
23.Palmer GM, Shortsleeve MJ. Gastric polyps due to extramedullary hematopoiesis. AJR 1998;171:531.
24.Kim SH, Han JK, Yoon CJ, et al. Gastric adenoma with atypical appearance: findings on double-contrast barium study with histopathologic correlation.Abdom Imaging 2000;25:124–128.
25.Ferrozzi F,Tognini G,Zuccoli G,Gabrielli M,Zangrandi A, Campani R. [Gastric stromal tumors. Findings with computerized tomography.] [Italian] Radiol Med 2000; 99:56–61.
26.Thompson WM, Kende AI, Levy AD. Imaging characteristics of gastric lipomas in 16 adult and pediatric patients. AJR 2003;181:981–985.
27.Galant J, Marti-Bonmati L, Saez F, Soler R, AlcalaSantaella R, Navarro M. The value of fat-suppressed T2 or STIR sequences in distinguishing lipoma from well-differentiated liposarcoma. Eur Radiol 2003;13: 337–343.
28.Theuer CP, Kurosaki T, Taylor TH, Anton-Culver H. Unique features of gastric carcinoma in the young: a population-based analysis. Cancer 1998;83:25–33.
29.Dorant E, van den Brandt PA, Goldbohm RA, Sturmans F. Consumption of onions and a reduced risk of stomach carcinoma. Gastroenterology 1996;110:12–20.
30.Adachi Y, Mori M, Maehara Y, Matsumata T, Okudaira Y, Sugimachi K. Surgical results of perforated gastric carcinoma: an analysis of 155 Japanese patients. Am J Gastroenterol 1997;92:516–518.
31.Arikawa J, Tokunaga M, Satoh E, Tanaka S, Land CE. Morphological characteristics of Epstein-Barr virusrelated early gastric carcinoma: a case-control study. Pathol Int 1997;47:360–367.
32.Kaneko S, Yoshimura T. Time trend analysis of gastric cancer incidence in Japan by histological types, 1975–1989. Br J Cancer 2001;84:400–405.
33.Park M-S, Ha HK, Choi BS, et al. Scirrhous Gastric Carcinoma: Endoscopy versus Upper Gastrointestinal Radiography. Radiology 2004;231:421–426.
34.Shindoh N, Nakagawa T,Ozaki Y, Kyogoku S, Sumi Y, Katayama H. Overlooked gastric carcinoma: pitfalls in upper gastrointestinal radiology. Radiology 2000;217: 409–414.
35.Takao M, Fukuda T, Iwanaga S, Hayashi K, Kusano H, Okudaira S. Gastric cancer: evaluation of triphasic spiral CT and radiologic-pathologic correlation. J Comput Assist Tomogr 1998;22:288–294.
36.Kim HS, Han HY, Choi JA, et al. Preoperative evaluation of gastric cancer: value of spiral CT during gastric arteriography (CTGA). Abdom Imaging 2001;26:123–130.
37.Lee DH, Ko YT. The role of 3D spiral CT in early gastric carcinoma. J Comput Assist Tomogr 1998;22:709–713.
38.Lee JH, Jeong YK, Kim DH, et al. Two-phase helical CT for detection of early gastric carcinoma: importance of the mucosal phase for analysis of the abnormal mucosal layer. J Comput Assist Tomogr 2000;24:777– 782.
39.Monig SP, Zirbes TK, Schroder W, et al. Staging of gastric cancer: correlation of lymph node size and metastatic infiltration. AJR 1999;173:365–367.
40.Dux M, Richter GM, Hansmann J, Kuntz C, Kauffmann GW. Helical hydro-CT for diagnosis and staging of gastric carcinoma. J Comput Assist Tomogr 1999;23: 913–922.
41.Rossi M, Broglia L, Graziano P, et al. Local invasion of gastric cancer: CT findings and pathologic correlation
105
STOMACH
using 5–mm incremental scanning, hypotonia, and water filling. AJR 1999;172:383–388.
42.Lim HK, Kim S, Lim JH, et al. Assessment of pancreatic invasion in patients with advanced gastric carcinoma: usefulness of the sliding sign on sonograms. AJR 1999;172:615–618.
43.Kim AY, Han JK, Kim TK, Park SJ, Choi BI. MR imaging of advanced gastric cancer: comparison of various MR pulse sequences using water and gadopentetate dimeglumine as oral contrast agents. Abdom Imaging 2000;25:7–13.
44.Sohn KM, Lee JM, Lee SY, Ahn BY, Park SM, Kim KM. Comparing MR imaging and CT in the staging of gastric carcinoma. AJR 2000;174(6):1551–1557.
45.Kang BC, Kim JH, Kim KW, et al. Value of the dynamic and delayed MR sequence with Gd-DTPA in the T-staging of stomach cancer: correlation with the histopathology. Abdom Imaging 2000;25:14– 24.
46.Marrelli D,Roviello F,De Stefano A,et al. Surgical treatment of gastrointestinal carcinomas in octogenarians: risk factors for complications and long-term outcome. Eur J Surg Oncol 2000;26:371–376.
47.Park KB, Do YS, Kang WK, et al. Malignant obstruction of gastric outlet and duodenum: palliation with flexible covered metallic stents. Radiology 2001;219: 679–683.
48.Jung GS, Song HY, Kang SG, et al. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology 2000;216:758–763.
49.Lee SS, Ha HK, Kim AY, et al. Primary extrapulmonary small cell carcinoma involving the stomach or duodenum or both: findings on CT and barium studies. AJR 2003;180:1325–1329.
50.Shikuwa S, Senju M, Tanaka H, et al. Progressive systemic sclerosis associated with primary small cell carcinoma of the stomach. [Review] J Gastroenterol 1997;32:538–542.
51.Hansen PB, Vogt KC, Skov RL, Pedersen-Bjergaard U, Jacobsen M, Ralfkiaer E. Primary gastrointestinal nonHodgkin’s lymphoma in adults: a population-based clinical and histopathologic study. J Intern Med 1998; 244:71–78.
52.Matsumoto S, Kohda K, Koike K, et al. [Diagnosis and prognosis of reactive lymphoreticular hyperplasia (RLH) or mucosa-associated lymphoid tissue (MALT) lymphoma.] [Japanese] Nippon Shokakibyo Gakkai Zasshi 1998;95:872–879.
53.Andoh A, Takaya H, Bamba M, et al. Primary gastric Burkitt’s lymphoma presenting with c-myc gene rearrangement. J Clin Gastroenterol 1998;33:710– 715.
54.Kinoshita K, Hirota S, Isozaki K, et al. Absence of c-kit gene mutations in gastrointestinal stromal tumours from neurofibromatosis type 1 patients. J Pathol 2004; 202:80–85.
55.Heinrich MC, Corless CL, Duensing A, et al. PDGFRA activating mutations in gastrointestinal stromal tumors. Science 2003;299:708–710.
56.Levy AD, Remotti HE, Thompson WM, Sobin LH, Miettinen M. Gastrointestinal stromal tumors: radiologic features with pathologic correlation. Radiographics 2003;23:283–304.
57.Ghanem N, Altehoefer C, Furtwangler A, et al. Computed tomography in gastrointestinal stromal tumors. Eur Radiol 2003;13:1669–1678.
58.Chak A, Canto MI, Rosch T, et al. Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc 1997;45:468–473.
59.Rha SE, Sohn KM, Lee SY, Jung HS, Park SM, Kim KM. Pedunculated exogastric leiomyoblastoma presenting as a wandering abdominal mass. Abdom Imaging 2000;25:545–547.
60.Sofka CM, Semelka RC, Marcos HB, Calvo BF, Woosley JT. Metastatic gastric leiomyoblastoma: a case report. Magn Reson Imaging 1998;16:343–346.
61.Seki K, Hasegawa T, Konegawa R, Hizawa K, Sano T. Primary liposarcoma of the stomach: a case report and a review of the literature. [Review] Jpn J Clin Oncol 1998;28:284–288.
62.Usuda H, Naito M. Multicentric angiosarcoma of the gastrointestinal tract. [Review] Pathol Int 1997;47:553– 556.
63.Kim JK, Won JH, Cho YK, Kim MW, Joo HJ, Suh JH. Glomus tumor of the stomach: CT findings. Abdom Imaging 2001;26:303–305.
64.Tsai SC, Hsieh JF, Ho YJ, Kao CH. Effects of butter and soybean oils on solid-phase gastric emptying in patients with functional dyspepsia. Abdom Imaging 2000;25:35–37.
65.Lauenstein TC, Vogt FM, Herborn CU, DeGreiff A, Debatin JF, Holtmann G. Time-resolved threedimensional MR imaging of gastric emptying modified by IV administration of erythromycin. AJR 2003;180:1305–1310.
66.Halkar RK, Paszkowski AL, Jones ME, et al. Two-point, timesaving method for measurement of gastric emptying with diagnostic accuracy comparable to that of the conventional method. Radiology 1999;213:599– 602
67.Trioche P, Chalas J, Francoual J, et al. Jaundice with hypertrophic pyloric stenosis as an early manifestation of Gilbert syndrome. Arch Dis Child 1999;81:301–303.
68.Hernanz-Schulman M, Lowe LH, Johnson J, et al. In vivo visualization of pyloric mucosal hypertrophy in infants with hypertrophic pyloric stenosis: is there an etiologic role? AJR 2001;177:843–848.
69.Yamamoto A, Kino M, Sasaki T, Kobayashi Y. Ultrasonographic follow-up of the healing process of medically treated hypertrophic pyloric stenosis. Pediatr Radiol 1998;28:177–178.
70.Veyrac C, Couture A, Bongrand AF, Baud C, Ferran JL. Atypical pyloric stenosis in an infant with familial hyperlipidemia. Pediatr Radiol 1996;26:402–404.
71.Graadt van Roggen JF, van Krieken JH. Adult hypertrophic pyloric stenosis: case report and review. [Review] J Clin Pathol 1998;51:479–480.
72.Skarsgard PL, Blair GK, Culham G. Balloon pyloroplasty in children with delayed gastric emptying. Clin Radiol 1998;41:151–155.
73.Kao CH, ChangLai SP, Chieng PU,Yen TC. Gastric emptying in male neurologic trauma. J Nucl Med 1998; 39:1798–1801.
74.O’Hara SM, Donnelly LF, Chuang E, Briner WH, Bisset GS 3rd. Gastric retention of zinc-based pennies: radiographic appearance and hazards. Radiology 1999;213: 113–117.
106
ADVANCED IMAGING OF THE ABDOMEN
75.McCaig J, Varghese JC, Rees MR. Case report: transdiaphragmatic gastric herniation: a rare complication of CABG using the right gastroepiploic artery. Clin Radiol 1996;51:143–145.
76.Privat C, Courthaliac C, Ravel A, Perez N, Boiteux JP, Boyer L. [CT and MRI features of a pseudo adrenal lesion: subcardial diverticulum.] [French] Prog Urol 1999;9:509–512.
77.Fabian G, Tovari E, Baranyay F, Czirjak L. Watermelonstomach as a cause of chronic iron deficiency anemia in a patient with systemic sclerosis. J Eur Acad Dermatol Venereol 1999;12:161–164.
78.Misra V, Misra SP, Dwivedi M. Thickened gastric mucosal capillary wall: a histological marker for portal hypertension. Pathology 1998;30:10–13.
79.Chang D, Levine MS, Ginsberg GG, Rubesin SE, Laufer I. Portal hypertensive gastropathy: radiographic findings in eight patients. AJR 2000;175:1609–1612.
80.Carucci LR, Levine MS, Rubesin SE, Laufer I. Tumorous gastric varices: radiographic findings in 10 patients. Radiology 1999;212:861–865.
81.Ninoi T, Nakamura K, Kaminou T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR 2004;183:369–376
82.Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998; 114:981–987.
83.Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices. Radiology 1999;211:349–356.
84.Contractor QQ, Contractor TQ, Kher YR. Sclerotherapy in bleeding gastric varices of hepatic schistosomiasis. J Clin Gastroenterol 1996;23:97–100.
85.Collazos J, Blanco MS, Mayo J, Martinez E. Gastrointestinal hemorrhage due to gastroduodenal involvement by Mycobacterium avium complex in a patient with acquired immune deficiency syndrome. J Clin Gastroenterol 1998;26:84–85.
86.Alcantara Gijon F, Bernal Bellido C, Ceballos Garcia R,
Gomez Munoz JC. [Gastric necrosis due to vasculitis in an HIV+ patient.] [Review] [Spanish] Rev Esp Enferm Dig 1999;91:152–153.
87.Mikala G, Xie J, Berencsi G, et al. Human herpesvirus 8 in hematologic diseases. [Review] Pathol Oncol Res 1999;5:73–79.
88.Zoller WG, Bogner JR, Powitz F, Liess H, Goebel FD. Endoscopic ultrasound in the diagnosis and staging of gastrointestinal Kaposi’s sarcoma. Endoscopy 1995;27: 191–196.
89.Carbognin G, Biasiutti C, El-Khaldi M, Ceratti S, Procacci C. Afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report. Abdom Imaging 2000;25:129–131.
90.Yu J, Turner MA, Cho S-R, et al. Normal anatomy and complications after gastric bypass surgery: Helical CT findings. Radiology 2004;231:753–760.
91.Smith TR,White AP. Narrowing of the proximal jejunal limbs at their passage through the transverse mesocolon: a potential pitfall of laparoscopic Roux-en-Y gastric bypass. AJR 2004;183:141–143.
92.Chevallier JM, Zinzindohoue F, Cherrak A, et al. [Laparoscopic gastroplasty for severe obesity. 300 cases, evaluation of the first 150.] [French] Presse Med 2000;29:1921–1925.
93.Wiesner W, Schob O, Hauser RS, Hauser M. Adjustable laparoscopic gastric banding in patients with morbid obesity: radiographic management, results, and postoperative complications. Radiology 2000;216:389– 394.
94.Rapp-Bernhardt U, Wolf S, Dohring W, Bernhardt TM. [Intragastric penetration as a local complication after performance of gastric banding.] [German] Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 2000;172:305–306.
95.Hainaux B,Coppens E,Sattari A,Vertruyen M,Hubloux G, Cadiere GB. Laparoscopic adjustable silicone gastric banding: radiological appearances of a new surgical treatment for morbid obesity. Abdom Imaging 1999;24:533–537.
96.Mortele KJ, Pattijn P, Mollet P, et al. The Swedish laparoscopic adjustable gastric banding for morbid obesity: radiologic findings in 218 patients. AJR 2001;177:77–84.
97.Van Rosendaal GM,Verhoef MJ, Mace SR, Kinsella TD. Decision-making and outcomes for percutaneous endoscopic gastrostomy: a pilot study. J Clin Gastroenterol 1997;24:71–73.
98.Laasch H-U, Wilbraham L, Bullen K, et al. Gastrostomy insertion: Comparing the options—PEG, RIG or PIG? Clin Radiol 2003;58:398–405.
99.Dinkel HP, Triller J. [Percutaneous gastrostomy with balloon PEG balloon replacement tubes by the radiologist. An interventional technique for simple placement of feeding catheters without surgical or endoscopic intervention.] [German] Radiologe 2001; 41:473–477.
100.Ryan JM, Hahn PF, Mueller PR. Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites. AJR 1998;171:1003–1006.
101.Dewald CL, Hiette PO, Sewall LE, Fredenberg PG, Palestrant AM. Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in 701 procedures. Radiology 1999;211:651–656.
102.Funaki B, Peirce R, Lorenz J, et al. Comparison of balloonand mushroom-retained large-bore gastrostomy catheters. AJR 2001;177:359–362.
103.Funaki B, Zaleski GX, Lorenz J, et al. Radiologic gastrostomy placement: pigtailversus mushroomretained catheters. AJR 2000;175:375–379.
104.Reimer W, Farres MT, Lammer J. Gastric wall dissection as a complication of percutaneous gastrostomy. Cardiovasc Intervent Radiol 1996;19:288–290.
105.Kanterman RY, Hicks ME, Simpson KR, Malden ES, Picus D, Darcy MD. Nonsurgical management of gastric or duodenal perforation from a Wills-Oglesby- type gastrostomy tube. J Vasc Interv Radiol 1996;7: 737–741.
106.Pickhardt PJ, Rohrmann CA Jr, Cossentino MJ. Stomal metastases complicating percutaneous endoscopic gastrostomy: CT findings and the argument for radiologic tube placement. AJR 2002;179:735–739.
107.Fleischer DE, Van de Mierop F, Eisen GM, et al. A new system for defining endoscopic complications emphasizing the measure of importance. Gastrointest Endosc 1997;45:128–133.
108.Barragan Casas JM, Hernandez Hernandez JM, Garcinuno Jimenez MA, et al. Bacteremia caused by digestive system endoscopy. Rev Esp Enferm Dig 1999; 91:105–116.
3
Duodenum
Congenital Abnormalities
Duplication
As in the rest of the gastrointestinal tract, a duodenal duplication may or may not communicate with the true lumen. Most duplications are located along the first and second parts of the duodenum. An occasional one is discovered incidentally, but most descending duodenal duplications coming to medical attention are associated with pancreaticobiliary abnormalities. An occasional one obstructs the common bile duct; at times a bizarre biliary communication is identified. A duplication can appear as a cystic tumor in the periampullary region. Some are associated with duodenal compression and obstruction or recurrent acute pancreatitis, a presentation more common in children. Rare complications of noncommunicating duodenal duplications include necrosis and perforation resulting in an acute abdomen, becoming infected or even causing an intussusception.
Ultrasonography (US) reveals a hyperechoic inner layer and a hypoechoic outer muscular layer; these layers are better defined with endoscopic US. At times peristaltic activity is identified.
Cholangiopancreatography is helpful in defining any associated ductal anomalies. Often endoscopic retrograde cholangiopancreatography (ERCP) is not successful due to periampullary distortion and magnetic resonance cholangiopancreatography (MRCP) is neces-
sary. A barium study aids in detecting duodenal communication and in narrowing the differential diagnosis considerably. With duodenal communication, the differential includes a duodenal diverticulum and a necrotic tumor. Without duodenal communication, other intramural or extrinsic tumors are in the differential. The presence of stones suggests communication with pancreaticobiliary ducts. With some of these duplications, computed tomography (CT), US, and magnetic resonance (MR) do not establish a site of origin, although imaging should differentiate a duodenal duplication from a choledochal cyst and pancreatic pseudocyst. Also, the clinical presentation is different with the latter two entities. In either case, the underlying pancreaticobiliary ductal anatomy is often atypical and should be defined prior to resection or anastomosis.
Atresia/Stenosis/Web
Duodenal atresia, believed to be due to failure of duodenal recanalization early in gestation, is the most common cause of a high bowel obstruction in a neonate. The most common site for atresia is just distal to the papilla of Vater, and these neonates present with bilious vomiting, whereas the less common atresia proximal to the papilla mimics gastric outlet obstruction. Atresias range from partial to complete; the atretic segment is either string-like or appears as a web.
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Table 3.1. Duodenal obstruction in the neonate
Midgut malrotation with volvulus
Duodenal atresia
Duodenal stenosis
Duodenal web
Ladd’s bands
Duodenal duplication
Annular pancreas
Anomalous portal vein anterior to duodenum
Tumor or distention in an adjacent structure
Not all neonatal duodenal obstruction is due to duodenal atresia or stenosis (Table 3.1). Midgut malrotation with volvulus in the newborn presents with complete duodenal obstruction and has a similar presentation.
Patients with duodenal atresia are prone to having other anomalies, including an annular pancreas and other pancreaticobiliary anomalies. A rare patient has an anomalous portal vein anterior to the duodenum. The prevalence of duodenal atresia is increased in Down syndrome, in a setting of congenital heart disease, and in those with a tracheoesophageal fistula. Esophageal atresia and duodenal atresia may coexist; in such a setting, unless a tracheoesophageal fistula is present, the stomach fills with fluid and distends. The large bowel is normal in these patients. A microcolon implies an additional, more distal obstruction.
A rare congenital duodenal obstruction in an infant leads to gastric emphysema (1).
An occasional adult develops a partial duodenal obstruction secondary to a web. Duodenal webs are associated with aspirin ingestion
(2) and long-term use of nonsteroidal antiinflammatory drugs (3).
Radiographs reveal no gas distal to the atresia. An exception is with a rare bifid common bile duct anomaly where the bile duct communicates both with proximal and distal duodenal segments.
After repair of duodenal atresia, the duodenal bulb continues to be larger in volume than usual.
Trauma
ADVANCED IMAGING OF THE ABDOMEN
wall thickening, at times to the point of obstruction. In its retroperitoneal position close to other major structures, duodenal trauma is commonly associated with injury to the adjacent pancreas and liver. An endoscopic biopsy is a cause of an intramural duodenal hematoma
(4). An intramural duodenal hematoma can develop secondary to pancreatitis. An abused child had both a duodenal hematoma and contained duodenal and proximal jejunal perforations (5); duodenal obstruction ensued and exploratory laparotomy found a calcified, fibrotic mesentery and both duodenal and jejunal strictures.
Full-thickness duodenal rupture does occur in patients sustaining blunt duodenal injury; the second duodenal segment is most often involved. Most of these ruptures are associated with other intraabdominal injuries, but one should keep in mind that traumatic retroperitoneal duodenal perforation initially reveals few clinical sign and symptoms. Blunt abdominal trauma can also result in diverticular perforation.
Imaging detection of an early duodenal perforation is difficult. For instance, among traumatic duodenal perforations studied with CT, extravasation of contrast is identified only in a small minority.
Blunt trauma is a common cause for a duodenal hematoma (Fig. 3.1). Imaging reveals duodenal
Figure 3.1. Duodenal hematoma (arrow) resulting in a highgrade obstruction. The obstruction resolved spontaneously.