Complete duodenal necrosis associated with non-traumatic duodenal hematoma requiring emergent pancreatico-duodenectomy

Introduction: Duodenal necrosis is a rare complication of acute pancreatitis but can occur given the shared blood supply to the head of the pancreas and the duodenum.

Presentation of case: A 55-year-old male presented with acute-on-chronic pancreatitis and a duodenal hematoma. The hematoma expanded to occlude the biliary tree and, shortly after, the duodenum necrosed and perforated. The patient required an emergent pancreaticoduodenectomy performed in two stages.

Discussion: Surgical management is complex and a difficult challenge for a general surgeon. Many advocate for wide drainage to create a controlled fistula using a malecot through the wall defect/separate duodenotomy/a retrograde jejunostomy tube. This case represents an extreme variation on this issue which was best managed by definitive resection given the extent of the necrosis.

Conclusion: This case report demonstrates that duodenal hematoma and necrosis should be recognized as part of the spectrum of consequences of acute pancreatitis. General surgeons should have a surgical approach to this complication whether that be diversion or definitive resection.