Basics
Description
- Characteristics of duodenum:
- 12 in long
- C-shaped
- From pylorus to ligament of Treitz
- Divided into 4 sections:
- Last 3 sections retroperitoneal along with distal portion of 1st section
- Lies mostly over 1st 3 lumbar vertebrae
- 2nd section is most commonly injured
- Types of injury:
- Duodenal wall hematoma
- Wall perforation
- Hemorrhage, including retroperitoneal
- Crush
- Incidence of duodenal injury is 3-5% of all traumatic abdominal injuries
- Penetrating trauma accounts for ~75% of duodenal injuries:
- Mortality ranges from 13-28%
- Associated with exsanguination
- Blunt duodenal trauma has a higher mortality due to greater force of injury and often delayed diagnosis due to retroperitoneal location:
- If injury is diagnosed in <24 hr, mortality rate is about 11%
- If >24 hr, mortality rate approaches 40%
- Late mortality usually from sepsis
- Majority secondary to recreational injuries (e.g., bicycle handlebar injuries)
- Intramural duodenal hematomas may occur in nonaccidental trauma:
- If suspected, prompt referral to appropriate child protective agency is required
- In children, hematoma is most commonly seen in 1st portion of duodenum
- Retroperitoneal hemorrhage more common due to increased pelvic and abdominal vascularity
- Large uterus serves as protection from bowel injury.
- Peritoneal irritation is blunted in the pregnant patient; therefore, greater index of suspicion
Etiology
- Blunt trauma:
- Shear strain: Abrupt acceleration/deceleration at point of attachment (most common retroperitoneal injury with rapid deceleration)
- Tensile strain: Direct compression or stretching of tissue
- Penetrating trauma:
- Most common cause of injury
- Creates cavitations, can lead to infection
Diagnosis
Signs and Symptoms
- Complaints may be minimal with vague abdominal, flank, and back pain
- High GI obstruction may be seen with duodenal hematomas
History
Penetrating or blunt abdominal trauma
Physical Exam
- Retroperitoneal: Often subtle, RUQ pain, nausea, vomiting, tachycardia, fever
- Intraperitoneal: Peritonitis
Essential Workup
- Basic labs including amylase
- Acute abdominal series or CT
- Diagnostic peritoneal lavage (DPL) or ex lap if unstable, high suspicion
Diagnosis Tests & Interpretation
Lab
- Lab tests are of little value
- 50% of patients with duodenal injuries have elevated serum amylase
- An increasing leukocytosis may suggest undiagnosed duodenal injury
Imaging
- Focused assessment with sonography in trauma (FAST)
- Validated for hemoperitoneum
- Not reliable for duodenal injury
- 1/3 retroperitoneal injuries with normal FAST
- Upright chest and abdominal radiographs:
- Intraperitoneal air
- Retroperitoneal air
- Air in biliary tree
- Scoliosis to the right
- Loss of psoas shadow
- Air around right kidney
- Injecting air into nasogastric tube may demonstrate retroperitoneal air more clearly
- Intramural hematomas without leakage may have coiled-spring appearance
- CT with oral and IV contrast:
- Best imaging diagnostic test that shows small amounts of retroperitoneal gas and extravasated contrast material
- Duodenal wall thickening, periduodenal fluid, "sentinel clot"¯ adjacent to injury
- Sausage-shaped mass in duodenal wall strongly suggests hematoma
Diagnostic Procedures/Surgery
- Ex lap is the ultimate diagnostic test when high suspicion remains, even after other diagnostic tests are negative
- DPL:
- Often positive for blood, bile, or bowel content
- Negative lavage does not exclude injury (65% false-negative rate)
Differential Diagnosis
- Injury to hollow organs (stomach, small and large intestines)
- Liver and biliary tree injuries
- Vascular injuries (aortic and mesenteric arteries as well as venous injuries)
- Postoperative complications from prior duodenal surgery or injury repair, such as infection and suture line dehiscence
Treatment
Pre-Hospital
- Follow trauma protocols
- Important to have pre-hospital personnel provide clear description of mechanism of injury and to transport to appropriate facility
Initial Stabilization/Therapy
- Airway management, resuscitation as needed
- Aggressive fluid therapy with warmed normal saline or lactated Ringer solution if patient hypotensive; transfuse as indicated
- Central line may be needed for unstable patients
- Nasogastric decompression
- Early trauma surgical consultation
Ed Treatment/Procedures
- Tetanus and antibiotic prophylaxis for penetrating wounds
- Definitive treatment involves laparotomy with exploration of duodenum for injuries
- Low-grade (I or II) blunt duodenal injuries usually managed nonoperatively - 10% fail
- Broad-spectrum antibiotics to prevent sepsis in patients with perforation
Medication
- Cefoxitin: 2 g (peds: 40 mg/kg) IV q6h or
- Levofloxacin 750 mg or Ciprofloxacin 400 mg q24h + Metronidazole 500 mg IV q8h
Follow-Up
Disposition
Admission Criteria
- All patients with duodenal injuries need admission to trauma surgical service
- Minor duodenal hematomas that do not require immediate surgery may require nasogastric decompression for obstruction (up to 7 days) and observation for possible expansion or rupture of the hematoma
Discharge Criteria
- No patient with identified traumatic duodenal injury should be discharged from the ED
- Complications: Intra-abdominal abscess, duodenal fistula, pancreatic fistula, sepsis
Issues for Referral
- Duodenal organ injury scale (DIS) by American Association for the Surgery of Trauma:
View LargeGradeDuodenal Injury DescriptionIHematoma: Single portion Laceration: Partial thickness, no perforationIIHematoma: >1 portionLaceration: Disrupts <50% circumference, spares ductIIILacerations only:-Disrupts 50-75% circumference D2-Disrupts 50-100% circumferenceD1, D3, D4IVLacerations only:-Disrupts >75% circumference D2-Involves ampulla or CBDVLaceration: Massive disruption duodenopancreatic complexVascular-devascularization - Majority injuries Grade II or Grade III
- 80% primary repairs
Follow-Up Recommendations
- All patients with diagnosed duodenal injury should be admitted
- If diagnostic studies are negative, recommend follow-up with PMD within 24-48 hr
- Diet: Clear liquids, advance as tolerated
Pearls and Pitfalls
- Significant morbidity and mortality with delayed or missed diagnosis
- Physical exam can be misleading due to retroperitoneal location
- If continued high suspicion despite negative diagnostic tests, get surgical consult
Additional Reading
- Chen GQ, Yang H. Management of duodenal trauma. Chin J Traumatol. 2011;14(1):61-64.
- Han JH, Hong SI, Kim HS, et al. Multilevel duodenal injury after blunt trauma. J Korean Surg Soc. 2009;77:282-286.
- Linsenmaier U, Wirth S, Reiser M, et al. Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology. Radiographics. 2008;28(6):1591-1602.
- Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma. 1990;30(11): 1427-1429.
See Also (Topic, Algorithm, Electronic Media Element)
- Abdominal Trauma, Blunt
- Abdominal Trauma, Imaging
- Abdominal Trauma, Penetrating
Codes
ICD9
- 863.21 Injury to duodenum, without open wound into cavity
- 863.31 Injury to duodenum, with open wound into cavity
ICD10
- S36.400A Unspecified injury of duodenum, initial encounter
- S36.420A Contusion of duodenum, initial encounter
- S36.430A Laceration of duodenum, initial encounter
- S36.490A Other injury of duodenum, initial encounter
SNOMED
- 125628003 Injury of duodenum (disorder)
- 111683002 Injury of duodenum without open wound into abdominal cavity (disorder)
- 210116008 Injury of duodenum with open wound into abdominal cavity (disorder)
- 262845003 Contusion of duodenum (disorder)
- 262850009 Laceration of duodenum (disorder)