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This is Pediatrics week 4 case 4 and

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the diagnosis under consideration is handlebar trauma

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and what we mean by handlebar trauma is any

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kind of direct blow to the anterior chest which

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in terms of the mechanism of injury has

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the effect of pinning the soft tissues

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of the mid epigastric region against

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the solid wall of the vertebral column

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and the things that can be injured are the bowel

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the stomach the pancreas the vessels

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and so anytime there is

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of course the namesake a bicycle handlebar impact

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or a car accident with a dashboard or whatever

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follows this pattern of injury. We are

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particularly concerned about those epigastric structures. So

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here the patient had a contrast enhanced CT

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performed to evaluate that region you can

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see we're in the upper abdomen the liver is brightly enhancing. I'm

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just gonna actually tone down some of that enhancement and

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then you can see the stomach is filled with

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Fluid and gas and here's our vertebral

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column here. This is the region of especially

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vulnerable structures to a

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kind of injury. So if you imagine that your force

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of impact is coming down straight like this

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and the backstop is this anything

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in here is at risk

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of getting squished. So that's what we're paying attention to in

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addition to everything else. We're paying particular attention to

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this region. We're going to scroll down through and here we've got

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all of these vessels which I can window down. There's no dissection. There's

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no transection of those vessels which

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that would be a big problem if there were

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But also we've got some pancreatic parenchyma wrapping around the body

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neck and head of the pancreas. It all looks homogeneous. No

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fluid collections. No separation of the tissue. However, it's

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catching my eye a little bit that there's fluid in

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this duodenal c-loop. And if

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I go back up, there's fluid up here. We usually don't see a

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lot of fluid hang out in a second third portions of the duodenum and

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as we come around to the fourth portion and it's going to wrap around

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to the midline. Look how it pancakes out what

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used to be a nice rounded fluid-filled tubular

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structure is becoming almost slit like

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and like a pancake collection of

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fluid and it suggests that the problem is that

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something is from the outside pushing against

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so if this is our little bit of bowel right

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here collapsed with very little fluid

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all the fluid is Upstream then what could

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be creating this Mass Effect. Well this structure right

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here and look how it's heterogeneous, and it's got

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dark areas and it's got slightly brighter.

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Am and as we scroll through it's quite obviously not

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a normal anatomic structure. It's collapsing the

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distal duodenum and I'm worried about what this might be. I'm especially

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concerned. There's a hematoma. So what would

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you want to do? Well, you want to evaluate the transit of materials

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through the stomach and through the bowel. So we're going to do an

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upper GI exam to evaluate.

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For duodenal patency. So here's

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our upper GI exam. We're giving contrast by

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mouth here. It goes through the esophagus nice

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esophageal column. We're not really worried about the esophagus. But

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there we have it. Let's look down at the stomach in the

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small bowel. That's where I'm concerned. Here's our stomach. This is

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a lateral view our spines off to the side. There's the pyloris allowing

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some contrast into the very beginning of the duodenum.

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It's going anti-grade but it's going

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retro peritoneal and here it goes dipping down just like

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we'd like to see hopefully it comes back up. Well,

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it's getting a little dilated kind of

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like what we saw on the CT not really coming back

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up. In fact that nice dilated

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bowel is starting to taper off to nothing and here's

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the frontal view. It's a little crooked but the patient

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must have been squirming on the table here. It's come out of the stomach. It's

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wrapping around and just kind of stopping

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And we're waiting and we're waiting and we're

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starting to see just what we saw on the CT exam contrast

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filling this proximal duodenum and

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then almost having a crescentic appearance

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or on the CT. It looked like a pancake where there's some

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invisible structure here squishing it closed. It's

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collapsed by extrinsic compression. And

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this is the classic appearance of a duodenal hematoma.

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We're bleeding occurs in the

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wall of the hematoma. It's intra mural and

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it expands the wall and collapses the

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Lumen of the duodenum. So we've got a

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in some ways the duodenum has become bigger because of

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all this blood in the wall, but the space where

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food and other ingested materials can pass through has become

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smaller.

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So we've got duodenal pseudo obstruction by a

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hematoma and this can become a problem.

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If it persists or if it's so complete that nothing can

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pass through so this is something that needs to be closely observed and

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hopefully it will resolve over time and

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evolution of the hematoma. But in certain cases

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it needs to be repaired or

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have some sort of intervention there can be tears in the wall that need

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to be resected. There could be complete obstruction of

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the bowel. So duodenal hematoma is a common injury

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from handlebar trauma needs to be recognized by the

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Radiologists so that we can handle the

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patients ingestion and fluid status appropriately. That's

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the end of the case.