CASE REPORT
Blunt Duodenal Trauma
Sumitoj Singh, Sudhir Khichy, Sarbjeet Singh, Deepak Bhangale, Satinder Pal Aggarwal and Varun Aggarwal
ABSTRACT
Duodenal trauma presents both diagnostic as well as management dilemma. In majority of duodenal trauma cases,
primary duodenal repair is sufficient. But in complex duodenal injuries, adjuvant procedures to protect suture line may
prove to be helpful. Herein, we share our experience of managing 4 cases of blunt duodenal injuries who presented in
emergency at the hospital from 2008 to 2011. All 4 cases had followed road traffic accidents. Their intra-operative findings,
operative procedures, complications, and recovery time were recorded and described.
Key words:
Blunt duodenal injury. Management. Trauma. Road traffic accident.
INTRODUCTION
Traumatic duodenal injuries are uncommon. Early
diagnosis is difficult due to its retroperitoneal location as
they present with mild pain abdomen to begin with,
which later becomes generalized due to leakage of
intestinal contents into peritoneal cavity.1 Due to its close
proximity to other structures, passage of large volume of
gastrointestinal secretions through it, and delay in the
diagnosis of its injuries, it causes therapeutic difficulties.1,2 The surgeons are in dilemma of either doing
simple repair or doing complex repairs.
Hereby, we report 4 cases of blunt traumatic duodenal
injuries with presentation and management.
CASE REPORT
Case 1: A 15 years old boy presented with history of a
roadside accident one day back. His complaints
were pain in abdomen and distension. There was
abdominal tenderness and rigidity. There was no air
under diaphragm on X-ray. On laparotomy, there was a
laceration on posterior-inferior wall of duodenum at
junction of third and fourth part of duodenum involving
50 – 60% circumference of duodenum (grade-III injury).
Primary closure with trans-pyloric duodenostomy and
feeding jejunostomy was done. Postoperatively, there
was bile leakage through abdominal drain, which was
managed conservatively.
Case 2: A 50 years old male was admitted with history
of road side accident 10 days back, during which
motorcycle handle hit the patient in epigastrium. Chief
complaints were pain in abdomen, distension, constipation, vomiting and breathlessness. He was being
Department of General Surgery, Guru Gobind Singh Medical
College and Hospital, Faridkot, Punjab, India.
Correspondence: Dr. Sumitoj Singh, 48, Medical College Campus,
Faridkot, Punjab, India.
E-mail: [email protected]
Received April 26, 2011; accepted December 04, 2012.
350
managed conservatively at district hospital and was
referred to our institute after he developed peritonitis.
Chest X-ray showed air under diaphragm. On laparotomy, there was perforation on posterior wall of
duodenopyloric junction near superior border of
pancreas measuring 2.5 x 1.5 cm in size (grade-II
injury). Closure of perforation, gastrostomy and feeding
jejunostomy was done. The postoperative period was
uneventful.
Case 3: A 50 years old male was admitted with history
of blunt trauma to abdomen sustained 6 days back in a
road traffic accident. He complained of abdominal
distension and pain. On examination, there was
abdominal distension and tenderness. On X-ray
examination, there was no air under diaphragm. On CT
abdomen, extra luminal air near paraduodenal area with
hemoperitoneum was seen. On exploratory laparotomy,
there were two lacerations, one on anterior and other on
posterior-lateral wall of second part of duodenum each
measuring 2 x 2 cm in size (grade-II injury, Figure 1).
Pyloric exclusion and feeding jejunostomy was
performed. During postoperative period, there was
duodenal leak and abdominal dehiscence, which were
managed conservatively. Oral contrast study after 3
weeks showed free flow of contrast through pylorus into
duodenum. He was discharged after 30 days.
Case 4: A 22 years old male presented with history of
road traffic accident while riding a motorcycle one day
before. He complained of vomiting and abdominal pain.
There was abdominal distension and tenderness. On
X-ray, there was air under diaphragm. On laparotomy,
there were two duodenal lacerations in second part of
duodenum 3 cm apart, proximal 2.5 x 2.5 cm on anterior
wall and distal laceration involving anterior, lateral and
posterior wall involving more than 75% circumference of
duodenum (grade-IV injury, Figure 2). The ampulla of
Vater was intact. Liver was lacerated. Pyloric exclusion
and feeding jejunostomy was done. Postoperatively he
had duodenal leak, abdominal dehiscence and gastrointestinal bleeding. Oral contrast study after 3 weeks
Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 350-352
Blunt duodenal trauma
Figure 1: Perforation in anterior and posteriorlateral wall of second part of duodenum.
Figure 2: Perforations in second part of duodenum, proximal 2.5 x 2.5 cm and distal laceration
involving anterior, lateral and posterior wall (~75%
circumference).
showed that pyloric patency was not re-established
(Figure 3). He was discharged after 45 days.
On follow-up, all 4 patients were doing well without any
complication.
DISCUSSION
Duodenal injuries constitute 3 – 5% of all abdominal
injuries and blunt duodenal injuries account for 20% of
all duodenal injuries.1 Duodenal injury occurs due to
crushing of duodenum against the spine or by shearing
force in blunt trauma abdomen. The second part of
duodenum is the most commonly injured followed by the
third, fourth, and first part in that order.
High index of suspicion is required for early diagnosis
because initial signs and symptoms may be subtle due
to its retroperitoneal position. Signs of peritonitis develop
late once the duodenal contents extravasate into the
peritoneal cavity.2 Two of the present cases were being
managed conservatively outside and referred after 10
and 6 days once the signs of peritonitis developed.
Routine laboratory tests, serum amylase levels, X-ray
and abdominal ultrasound are not of much help in
diagnosis of duodenal trauma.3-5 Air under diaphragm
was present in 2 out of 4 patients on X-ray. In
hemodynamically stable cases, CECT abdomen is the
investigation of choice for the detection of peritonitis and
perforation.
Blunt or missile duodenal injury, associated injuries to
pancreas and common bile duct injuries, involvement of
more than 75% of the duodenal wall, injury to first or
second part of duodenum, time interval more than 24
hours between injury and repair are associated with
increased risk of duodenal repair dehiscence with
increased morbidity and mortality and are considered
complex injuries.6
The majority of duodenal injuries are managed by
debridement and primary repair. If primary closure of the
defect narrows the lumen of the bowel or results in
undue tension then segmental resection and primary
end-to-end duodenoduodenostomy or a Roux-en-Y
Figure 3: Oral contrast study showing that pyloric
patency not re-established after pyloric exclusion.
jejunal limb anastomosis to the proximal duodenal injury
with oversewing of the distal duodenal or serosal patch
technique (serosa of a loop of jejunum is sutured to the
edges of the duodenal defect injury) is performed
whenever possible. The major concern in primary repair
of complex injuries is high incidence of dehiscence of
repair with resultant abdominal septic complications. To
protect the duodenal repair in complex duodenal injuries
several procedures are described to divert the
gastrointestinal secretions from suture line which may
help in the management of duodenal fistula. In this
series, an adjuvant procedure was done in all the cases
as they had complex injuries. All patients had controlled
duodenal fistula which was managed conservatively.
Post-operative feeding was through feeding jejunostomy
and it helps in reducing the mortality.7
Tube decompression (gastrostomy, duodenostomy, and
jejunostomy) was introduced by Stone and Fabian in
trauma patients.8 Retrograde duodenodenal drainage
through retrograde jejunostomy is preferred to lateral
duodenostomy. Tube duodenostomy should be placed
transpyloric as it decompresses duodenum proximal to
the suture line and avoids new duodenal holes.1 We
placed transpyloric tube duodenostomy in one case.
Although he had duodenal leak but it effectively drained
the duodenum; it probably helped in healing the fistula
early by decreasing the fistula output.
Duodenal diverticulization involves repair of perforation,
Billroth-II gastrostomy, vagotomy, end tube duodenostomy and T-tube in common bile duct.9 It is replaced by
pyloric exclusion which includes repair of duodenum,
gastrostomy along greater curvature of antrum, closure
of pyloric ring with running suture through gastrostomy
and gastrojejunostomy at gastrostomy site. It is
technically easier, less radical and achieves the same
effect with decreased operative time. Restoration of
pyloric patency occurs in 94% of the patients after 3
weeks irrespective of type of closure. Pyloric exclusion
decreases postoperative leak from 43 – 12% in gradeIII injuries.10 Pyloric exclusion performed in 2 cases and
both had duodenal leak. Oral contrast study was done in
Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 350-352
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Sumitoj Singh, Sudhir Khichy, Sarbjeet Singh, Deepak Bhangale, Satinder Pal Aggarwal and Varun Aggarwal
4.
Olsen WR. The serum amylase in blunt trauma. J Trauma 1973;
13:200-4.
5.
Flint LM Jr, McCoy M, Richardson JD, Polk HC Jr. Duodenal
injury. Analysis of common misconceptions in diagnosis and
treatment. Ann Surg 1980; 191:697-701.
6.
Snyder WH 3rd, Weigelt JA, Watkins WL, Bietz DS. The surgical
management of duodenal trauma. Precepts based on a review
of 247 cases. Arch Surg 1980; 115:422-9.
The duodenal injury related mortality is due to fistula
formation, intra-abdominal abscess, sepsis, multi-organ
failure and ranges from 6.5% to 12.5%.2
7.
Antonacci N, Di Saverio S, Ciaroni V, Biscardi A, Giugni A,
Cancellieri F, et al. Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of
outcome? J Hepatobiliary Pancreat Sci 2011; 18:195-201.
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both cases after 3 weeks and in one patient pylorus
patency was not re-established. In one patient in whom
pyloric patency was re-established the fistula output was
more and it took more time for the fistula to close.
Pancreatoduodenectomy is indicated in grade-IV and V
injuries. Mortality with this procedure in trauma is
30 – 40%.1
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Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 350-352