an intramural duodenal hematoma ( idh ) with duodenal obstruction is usually a complication of blunt abdominal trauma , endoscopic biopsy , or peptic ulcer disease.1 in particular , non - traumatic idh is associated with coagulation abnormalities . however , few cases of idh caused by acute pancreatitis have been reported.2 the presentation of spontaneous idh can vary from mild abdominal pain to intestinal tract obstruction and acute abdomen . most patients with non - extensive hematoma will show improvement with non - operative treatments such as nasogastric decompression and correction of abnormal coagulation . percutaneous drainage or surgery may be necessary in cases with suspected malignancy , perforation , or intestinal tract obstruction . here , we present a case of idh in which duodenal obstruction was caused by acute pancreatitis and an experience of successful endoscopic decompression of the hematoma . a 55-year - old man who had been experiencing right upper abdominal pain and vomiting for 2 days was admitted to the hospital . he had been treated previously for alcoholic pancreatitis caused by heavy drinking and had no history of antiplatelet , anticoagulants , or non - steroidal anti - inflammatory drug use . laboratory analysis showed mild leukocytosis ( 13,850 cells/l ) and marked elevation of serum pancreatic enzyme levels ( amylase , 1,001 u / l ; lipase , 1,809 u / l ) . activated partial thromboplastin time and prothrombin time were measured at 30.4 seconds and 10.1 seconds , respectively , which were within their normal ranges . computed tomography ( ct ) revealed a highly attenuated mass along the duodenum and acute pancreatitis ; the mass narrowed the lumen , causing significant distension of the stomach and mild pancreatic swelling with peripancreatic infiltration ( fig . upper endoscopy revealed a submucosal mass with a hyperemic mucosa in the duodenal bulb and complete obstruction of the second duodenal portion caused by external compression . a tiny erosion was found on the surface of the duodenal hematoma , suggesting the presence of fistula between duodenal lumen and hematoma . we decided to perform rapid decompression of this hematoma in order to resolve the gastric outlet obstructive symptoms and the nothing per oral ( npo ) period . we removed the mucosa at the erosive surface of the mass using biopsy forceps and made a small fistula . after the blood had flowed out , we carefully advanced an endoscope through the fistula and observed the presence of blood clots with oozing . therefore , we removed some of the clots using a basket and suctioned them to decompress the luminal obstruction ( fig . conservative therapies such as fluid therapy and npo were continued , and the patient 's symptoms and abnormal laboratory findings improved after 1 week . in a follow - up ct scan of the abdomen conducted after 2 weeks , the previously large mass was found to be smaller ( fig . 3 ) . only a small duodenal ulcer was found after 18 days ( fig . idh with duodenal obstruction is usually a complication of trauma.1 non - traumatic idh is generally associated with coagulation abnormalities.3 however , few cases of idh caused by acute pancreatitis have been reported.2 non - traumatic idh can cause intestinal stenosis , often initially presenting as abdominal pain and vomiting.4 obstructive symptoms from duodenal hematomas generally resolve in 10 to 15 days ; however , some patients experience a prolonged course with persistent duodenal obstruction that requires operative exploration.5 intensive medical therapy is now gaining wide acceptance with recent advances in diagnostic imaging techniques.6 in the current case , the large hematoma was treated adequately with endoscopic evacuation of the hematoma through a fistula that was created at the erosive surface using biopsy forceps , and after this treatment , the symptoms of gastric outlet obstruction improved rapidly . in our patient , it is not clear if the acute pancreatitis occurred because of the hematoma , probably due to obstruction of the duodenal papilla , or if the compression of the pancreas was caused by the hematoma ; however , the patient did not experience any traumatic event or have a suspect medication history , although he did drink a significant amount of alcohol before being admitted to the hospital for abdominal pain . therefore , we believe that acute pancreatitis was the likely cause of duodenal hematoma with gastric obstruction . to the best of our knowledge , this is the first case of successful endoscopic decompression for idh with gastric outlet obstruction caused by acute pancreatitis . although the effectiveness of endoscopic decompression for idh has not been proved because idh is rare , we hope our experience will allow patients to avoid more invasive procedures in the future .
non - traumatic intramural duodenal hematoma ( idh ) with duodenal obstruction caused by acute pancreatitis is rare . 
 most patients with non - extensive hematoma show improvement with non - operative treatments . 
 percutaneous drainage or surgery may be necessary in cases with suspected malignancy , perforation , or intestinal tract obstruction . 
 we present a case of idh caused by acute pancreatitis that led to obstruction of the duodenum and an experience of successful endoscopic decompression of the hematoma .