Delayed rupture of a jejunal subserosa hematoma following blunt abdominal trauma: A case report and review of literature

Abstract

BACKGROUND

Traumatic subserosa hematoma of the proximal jejunum with delayed rupture and hemorrhage is exceedingly rare, especially without anticoagulation. No prior reports document spontaneous rupture precisely on day 5 post-blunt trauma. This case uniquely demonstrates this delayed pattern, initial computed tomography (CT) misdiagnosis as a retroperitoneal neoplasm due to Treitz ligament proximity, and conservative management failure, offering novel insights into its unpredictable course and the need for prompt surgical intervention in non-coagulopathic patients.

CASE SUMMARY

A 21-year-old male delivery courier sustained blunt upper abdominal trauma from a tricycle handlebar impact during a motor vehicle accident. Initial symptoms were mild abdominal pain and distension. Symptoms worsened on day 2 with nausea and vomiting; admission CT showed a retroperitoneal cystic mass with hemorrhage, misdiagnosed as duodenal gastrointestinal stromal tumor. Conservative management was initiated. On hospital day 4 (post-injury day 5), sudden severe pain, hypotension (90/45 mmHg), and tachycardia developed. Bedside ultrasound confirmed massive hemoperitoneum. Emergency laparotomy revealed a 10-cm ruptured subserosal hematoma at the proximal jejunum near the ligament of Treitz with active oozing; hematoma evacuation and serosal repair were performed. Postoperative course was uneventful; oral intake resumed on day 3, no contrast swallow X-ray was performed due to clinical stability, and he was discharged on day 7. One-month follow-up CT showed complete resolution.

CONCLUSION

This rare traumatic proximal jejunal subserosal hematoma ruptured on day 5 without anticoagulation, highlighting the need for early CT with Treitz focus, serial monitoring, and prompt laparotomy. This study is limited by its single-case, retrospective design and the lack of long-term follow-up data.

Key Words: Jejunal subserosa hematoma; Blunt abdominal trauma; Delayed rupture; Intraperitoneal hemorrhage; Laparotomy; Case report

Core Tip: This exceedingly rare case of traumatic proximal jejunal subserosal hematoma without anticoagulation history demonstrates delayed rupture on day 5 after blunt abdominal trauma, leading to intraperitoneal hemorrhage despite initial conservative management. Initial computed tomography misdiagnosed it as a retroperitoneal cystic mass near the ligament of Treitz. Clinicians should maintain high suspicion in blunt trauma, perform early contrast-enhanced computed tomography focusing on Treitz fixation, conduct serial monitoring, and proceed to urgent laparotomy upon any sign of expansion or bleeding to prevent life-threatening complications.

INTRODUCTION

Blunt abdominal trauma can cause a spectrum of intra-abdominal injuries, from solid organ lacerations to rare hollow viscus disruptions. Subserosa hematomas of the jejunum without delay rupture are exceptionally uncommon in non-anticoagulated patients[1]. We here report a young male with delayed rupture of a proximal jejunal subserosal hematoma five days after handlebar injury, initially misdiagnosed on computed tomography (CT) as a duodenal stromal tumor, ultimately requiring emergency laparotomy and serosal repair. This case adds novel evidence on the rare delayed rupture timing and failure of conservative management in trauma-induced cases without coagulopathy.

CASE PRESENTATION

Chief complaints

A 21-year-old male delivery courier presented with progressive abdominal pain after a motor vehicle accident.

History of present illness

One day prior to admission, the patient sustained blunt upper abdominal trauma when the handlebar of a tricycle directly struck his epigastrium during a traffic collision at low speed. He experienced mild abdominal pain and distension, which were tolerable, so he did not seek immediate care. On the second day, pain and distension worsened with nausea and vomiting, leading to emergency department presentation. Admission vital signs were stable. Conservative management included bed rest, intravenous fluids, and hemostatic agents (e.g., tranexamic acid). On hospital day 4 (post-trauma day 5), sudden severe abdominal pain occurred with hypotension (90/45 mmHg) and tachycardia (102 bpm). Bedside ultrasonography showed large free intraperitoneal fluid suggestive of hemoperitoneum. Emergency exploratory laparotomy was performed.

History of past illness

No significant past medical history.

Personal and family history

No regular medications, and no relevant family history.

Physical examination

On admission: Stable vitals; mild upper abdominal tenderness without rebound or guarding.

On day 4 after admission: Blood pressure 90/45 mmHg, heart rate 102 bpm, marked worsening upper abdominal tenderness without rebound or rigidity.

Laboratory examinations

On admission: White blood cell count: 12.1 × 10⁹/L; hemoglobin 149 g/L; C-reactive protein 6.7 mg/L; prothrombin time 12.6 seconds; and activated partial thromboplastin time 35 seconds. All other parameters, including liver function tests, tumor markers, electrolytes, and routine blood tests, were within normal limits.

Imaging examinations

Admission abdominal contrast-enhanced CT demonstrated an incomplete fracture of the left ninth rib and a retroperitoneal cystic mass with internal hemorrhage in the left upper quadrant, initially interpreted as a possible duodenal gastrointestinal stromal tumor (Figure 1). On hospital day 4, emergency bedside ultrasound revealed massive free intraperitoneal fluid consistent with hemoperitoneum.

Figure 1 Contrast-enhanced computed tomography on admission. A: Non-contrast phase: A round-like hypodense lesion with well-defined margins and heterogeneous internal density, showing areas of slightly higher attenuation; B: Arterial phase: Wall enhancement is observed, while the interior of the lesion shows no enhancement, with an indistinct boundary between the lesion and the duodenum; C: Venous phase: Findings similar to those in the arterial phase.

FINAL DIAGNOSIS

Blunt abdominal trauma with delayed rupture of a proximal jejunal subserosa hematoma, intraperitoneal hemorrhage, and left ninth rib fracture.

TREATMENT

Emergency exploratory laparotomy revealed approximately 1500 mL hemoperitoneum (mainly perihepatic, perisplenic, pelvic). A 10-cm subserosa hematoma with partial rupture and active oozing was found at the beginning of the jejunum, near the ligament of Treitz (Figure 2). The hematoma was evacuated, and the serosal defect was repaired with interrupted sutures (Video). No additional injuries were found. The peritoneal cavity was thoroughly irrigated, hemostasis confirmed, and the abdomen closed. Initial conservative strategy considered due to hemodynamic stability and no peritonitis; however, deterioration prompted surgery. Laparoscopic approach not adopted due to anatomical complexity near Treitz ligament and risk of incomplete evacuation.

Figure 2 Intraoperative findings. A: Large hematoma; B: Following evacuation of the hematoma, serosal rupture was observed; C: Serosal repair. White arrows indicate the serosal edge; black arrows indicate the jejunal muscular layer.

OUTCOME AND FOLLOW-UP

The postoperative course was uneventful. Nasogastric tube removed on day 3; oral liquids started day 3, solid diet day 5. No routine postoperative oral contrast X-ray performed due to clinical stability and absence of obstructive symptoms. Discharged on day 10. One-month follow-up CT confirmed complete resolution with no recurrence (Figure 3).

Figure 3  No intra-abdominal effusion or mass was found on computed tomography one month later.

DISCUSSION

Diagnostic and therapeutic challenges in traumatic jejunal hematomas

Intramural hematomas of the small intestine are rare gastrointestinal disorders, primarily manifesting as hematoma formation within the intestinal wall, often leading to local obstruction or bleeding. Their epidemiological characteristics indicate an extremely low incidence. Literature consistently reports an annual incidence of approximately 1/2500 among patients receiving anticoagulant or antiplatelet therapy, and even rarer in the general population particularly prevalent in middle-aged and elderly patients or those with underlying coagulation disorders[1-3]. In the reported literature, most cases of subserosal hematoma are associated with a history of anticoagulation[4-6]. These lesions pose significant diagnostic and therapeutic challenges due to their nonspecific presentation, often limited to abdominal pain, bloating, nausea, or vomiting - and the potential for delayed, life-threatening hemorrhage[7-9]. A comprehensive search of PubMed and Google Scholar using the keywords “jejunal hematoma”, “subserosal hematoma”, “intramural hematoma”, “delayed rupture”, “blunt abdominal trauma”, and “proximal jejunum” (limited to English-language publications from 1950 to 2025 and excluding non-traumatic cases or those solely related to anticoagulation without a trauma context) yielded no matching reports documenting delayed rupture and hemorrhage of a subserosal or intramural hematoma in the absence of anticoagulant use

Clinical presentation is nonspecific, typically limited to abdominal pain, nausea, vomiting, bloating, or distension, mimicking intestinal obstruction, splenic rupture, pancreatic injury, or acute abdomen[10-13]. Delayed obstruction or rupture (≥ 48 hours post-injury) occurs in 20%-30% of cases due to gradual hematoma expansion, escalating intraluminal pressure, or secondary ischemic necrosis of the intestinal wall, exacerbated by mechanical stress from high-energy trauma[14,15]. The duodenojejunal junction, fixed by the ligament of Treitz, is a preferred site for traumatic hematomas owing to its limited mobility and vulnerability to shear forces; rupture can cause intra-abdominal hemorrhage (as in this case) or massive intraluminal bleeding, often manifesting as delayed symptoms[13,14]. Abbas et al[16] reported complete obstruction from jejunal intramural hematoma in a child with similar trauma mechanism related to Treitz fixation. Kumar et al[17] described mesenteric hematoma from spontaneous jejunal aneurysm rupture causing secondary duodenal obstruction.

A distinguishing feature of this case was hematoma rupture on day 5 post-injury, resulting in intraperitoneal hemorrhage - a delayed presentation uncommon in traumatic small bowel hematomas without anticoagulation. Such progression likely stems from gradual hematoma expansion, increasing local pressure, or secondary ischemia, amplified by high-energy handlebar impact[18]. Contrast-enhanced abdominal CT remains the gold standard for diagnosis, reliably depicting circumferential wall thickening, high-density subserosal/intramural hematomas, luminal narrowing, and intraperitoneal fluid[19,20]. Routine use in post-traumatic abdominal pain facilitates early detection and rupture risk assessment. In this instance, initial CT showed a well-circumscribed retroperitoneal cystic lesion with internal hemorrhagic components in the left upper quadrant, initially interpreted as a possible duodenal gastrointestinal stromal tumor. Retrospective analysis reveals that the lesion’s cystic appearance with heterogeneous internal density, absence of solid enhancement, and proximity to the duodenum/Treitz ligament contributed to diagnostic uncertainty. Differentiation from mimics (gastrointestinal stromal tumors[21,22], cysts[23-25], pseudoaneurysms[26]) relies on CT characteristics: Hematomas exhibit irregular, high-density hemorrhagic areas without solid enhancement, whereas gastrointestinal stromal tumors display heterogeneous enhancement and extraluminal growth, cysts appear low-density and anechoic, and pseudoaneurysms show arterial contrast extravasation[20,27]. The proximal jejunum’s retroperitoneal position near Treitz can produce atypical cystic-appearing masses, further blurring distinctions. More plausible preoperative differentials in trauma context include cystic retroperitoneal schwannoma with hemorrhage (typically heterogeneous with cystic degeneration and possible enhancement of solid components)[28], hemorrhagic cystic lymphangioma (multiloculated low-density cystic mass with fluid-fluid levels)[29], and ganglioneuroma (less likely, often homogeneous or mildly enhancing)[29]. These entities share overlapping features with hematoma (non-enhancing high-density areas), but the history of recent blunt trauma, lack of progressive enhancement, and location fixed at Treitz should have raised suspicion for traumatic etiology. Emphasizing Treitz ligament fixation as an anatomical landmark could enhance localization accuracy and reduce misinterpretation[12]. Obstructive features were absent initially, consistent with small hematoma size; CT typically shows air-fluid levels in obstruction vs high-density masses in hematomas. Multidisciplinary review of serial CTs is advocated to refine differentials and avert management delays. Literature indicates that small, asymptomatic small bowel hematomas can resolve with conservative management (bed rest, nasogastric decompression, fluid support)[8,17], with approximately 70% of patients avoiding surgery[11,16]. Initial conservative approach in this case was justified by hemodynamic stability, absence of peritonitis, and no active extravasation on CT, consistent with World Society of Emergency Surgery guidelines recommending non-operative management for stable blunt bowel injuries without perforation or shock[30].

Interventions include serosal repair for intact wall (minimally invasive, preserves function, low complication rate) vs resection for necrosis/perforation (higher risk of short-bowel syndrome or anastomotic leak). Surgical outcomes in contemporary reports show mortality < 5% with prompt intervention; complications (infection, fistula, recurrent obstruction) occur in 10%-20%[26,27,31]. Alternative strategies include transarterial embolization for active extravasation in select stable cases or endoscopic drainage (rarely feasible). Laparoscopic approaches are limited by anatomical complexity near Treitz and risk of incomplete evacuation. In this case, conservative treatment was initially appropriate given hemodynamic stability, but deterioration mandated open laparotomy; serosal repair succeeded without resection. The proximal jejunum’s fixation by Treitz ligament and adjacency to pancreas/duodenum increased surgical complexity, necessitating careful dissection to avoid superior mesenteric artery injury or secondary fistulas - thus laparoscopic surgery was not adopted[32].

In summary, this case underscores the unpredictable evolution of traumatic proximal jejunal subserosal hematomas, even in young non-anticoagulated patients. Early contrast-enhanced CT with Treitz landmark emphasis, serial clinical/Laboratory/imaging monitoring, and prompt surgical intervention upon signs of rupture or shock are essential to prevent life-threatening outcomes.

Patient perspective

I never imagined a simple fall from my tricycle could lead to something so serious. I experienced mild abdominal pain and distension, which were tolerable, and did not seek medical attention at first. But over the next two days, the pain grew sharper, and I started feeling weak. When they finally discovered the bleeding inside my jejunum and told me that I needed emergency surgery, I was terrified. The surgical team was incredibly calm and kind; they explained there was bleeding in my abdominal cavity and laparotomy should be performed. Waking up after the operation, I was relieved to hear they had successfully removed the ruptured hematoma and that my bowel was safely repaired. The nurses in the ward were patient with my questions and made sure I was comfortable while I recovered with pain relief. Looking back, I’m so grateful for the quick decisions made by the medical team. The first CT scan had been misread as something less urgent, but when my condition suddenly worsened, they didn’t hesitate to take me straight to the operating room. That second scan and their vigilance literally saved my life. I’m now back to normal activities. This experience taught me never to ignore persistent abdominal pain after a fall, no matter how minor the accident seems. I hope by sharing my story, others will seek help sooner and doctors will remember that even young, active people without anticoagulation can suffer serious internal bleeding from trauma.

CONCLUSION

This rare case of traumatic proximal jejunal subserosal hematoma with delayed rupture on day 5 post-blunt trauma illustrates the diagnostic pitfalls and limitations of conservative management, ultimately requiring emergency laparotomy and successful serosal repair to control intraperitoneal hemorrhage. Evidence-based recommendations include routine early contrast-enhanced CT with emphasis on Treitz ligament fixation for accurate localization, serial clinical, laboratory, and imaging monitoring for at least 72 hours, and prompt surgical intervention upon any sign of hematoma expansion, peritonitis, or hemorrhagic shock, aligning with contemporary trauma guidelines. Clinically, it reinforces heightened suspicion for small bowel injuries in high-energy blunt abdominal trauma - even in young, non-anticoagulated patients - to minimize delays and life-threatening complications. Limitations of this report include its single-case nature, retrospective design, absence of long-term follow-up beyond one month. Future research opportunities encompass larger multicenter series to identify predictors of delayed rupture, development of specific imaging biomarkers (e.g., texture analysis or perfusion CT), establishment of standardized dynamic monitoring protocols, and quantitative evaluation of high-energy trauma’s role in hematoma progression without coagulopathy.

ACKNOWLEDGEMENTS

We are grateful to those who are involved in this report for their dedication and collaboration, Thanks to Shan Xiao-Han for taking and modifying the picture.