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Duodenal Trauma, Emergency Medicine

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Duodenal Trauma, Emergency Medicine

Basics

Description

  • Characteristics of duodenum:12 in longC-shapedFrom pylorus to ligament of TreitzDivided into 4 sections:Last 3 sections retroperitoneal along with distal portion of 1st sectionLies mostly over 1st 3 lumbar vertebrae2nd section is most commonly injured
  • Types of injury:Duodenal wall hematomaWall perforationHemorrhage, including retroperitonealCrush
  • 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
  • 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
  • Last 3 sections retroperitoneal along with distal portion of 1st section
  • Duodenal wall hematoma
  • Wall perforation
  • Hemorrhage, including retroperitoneal
  • Crush
  • Mortality ranges from 13-28%
  • Associated with exsanguination
  • 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
  • If suspected, prompt referral to appropriate child protective agency is required
  • 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 injuryCreates cavitations, can lead to infection
  • Shear strain: Abrupt acceleration/deceleration at point of attachment (most common retroperitoneal injury with rapid deceleration)
  • Tensile strain: Direct compression or stretching of tissue
  • 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
  • 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 tests are of little value
  • 50% of patients with duodenal injuries have elevated serum amylase
  • An increasing leukocytosis may suggest undiagnosed duodenal injury
  • Focused assessment with sonography in trauma (FAST)Validated for hemoperitoneumNot reliable for duodenal injury1/3 retroperitoneal injuries with normal FAST
  • Upright chest and abdominal radiographs:Intraperitoneal airRetroperitoneal airAir in biliary treeScoliosis to the rightLoss of psoas shadowAir around right kidneyInjecting air into nasogastric tube may demonstrate retroperitoneal air more clearlyIntramural 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 materialDuodenal wall thickening, periduodenal fluid, "sentinel clot"¯ adjacent to injurySausage-shaped mass in duodenal wall strongly suggests hematoma
  • Validated for hemoperitoneum
  • Not reliable for duodenal injury
  • 1/3 retroperitoneal injuries with normal FAST
  • 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
  • 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
  • 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 contentNegative lavage does not exclude injury (65% false-negative rate)
  • 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

  • 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
  • No patient with identified traumatic duodenal injury should be discharged from the ED
  • Complications: Intra-abdominal abscess, duodenal fistula, pancreatic fistula, sepsis
  • 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)