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IEmergency And Acute Medicine – Duodenal Trauma
Basics Description
The duodenum is a 12-inch long, C-shaped structure extending from the pylorus to the ligament of Treitz and is divided into four sections. The distal portion of the first section and the remaining three sections are retroperitoneal. It lies mostly over the first three lumbar vertebrae, with the second portion being the most commonly injured. Types of injury include duodenal wall hematoma, wall perforation, hemorrhage including retroperitoneal bleeding, and crush injury. Duodenal trauma accounts for 3–5% of all traumatic abdominal injuries. Penetrating trauma causes approximately 75% of cases, with mortality ranging from 13–28%, often due to exsanguination. Blunt trauma carries higher mortality because of greater injury force and delayed diagnosis related to the retroperitoneal location. If diagnosed within 24 hours, mortality is approximately 11%; if delayed beyond 24 hours, mortality approaches 40%, with late deaths commonly due to sepsis.
Pediatric Considerations
Most pediatric duodenal injuries result from recreational trauma such as bicycle handlebar injuries. Intramural duodenal hematomas may be associated with nonaccidental trauma; suspected cases require immediate referral to child protective services. In children, hematomas most commonly involve the first portion of the duodenum.
Pregnancy Considerations
Retroperitoneal hemorrhage is more common due to increased abdominal and pelvic vascularity. The enlarged uterus may provide partial protection from bowel injury, and peritoneal irritation may be blunted, necessitating a higher index of suspicion.
Etiology
Blunt trauma mechanisms include shear strain from rapid acceleration–deceleration at points of fixation and tensile strain from direct compression or stretching. Penetrating trauma is the most common cause overall and may create cavitation with subsequent infection.
Diagnosis Signs And Symptoms
Symptoms may be minimal and nonspecific, including vague abdominal, flank, or back pain. High gastrointestinal obstruction may occur with duodenal hematomas.
History
Penetrating or blunt abdominal trauma.
Physical-Exam
Retroperitoneal injury may present subtly with right upper quadrant pain, nausea, vomiting, tachycardia, and fever. Intraperitoneal involvement presents with signs of peritonitis.
Essential Workup
Obtain basic laboratory studies including amylase. Perform an acute abdominal series or CT imaging. Diagnostic peritoneal lavage or exploratory laparotomy is indicated in unstable patients with high clinical suspicion.
Diagnosis Tests And Interpretation
Laboratory studies are generally nonspecific; approximately 50% of patients have elevated serum amylase, and rising leukocytosis may suggest missed injury. FAST examination is validated for hemoperitoneum but is unreliable for duodenal injury, with one-third of retroperitoneal injuries having a normal FAST. Upright chest and abdominal radiographs may show intraperitoneal or retroperitoneal air, air in the biliary tree, rightward scoliosis, loss of psoas shadow, or air around the right kidney. Air insufflation via nasogastric tube may enhance detection of retroperitoneal air. Intramural hematomas may show a coiled-spring appearance. CT with oral and IV contrast is the preferred diagnostic modality, identifying retroperitoneal gas, contrast extravasation, duodenal wall thickening, periduodenal fluid, sentinel clot, or sausage-shaped intramural masses. Exploratory laparotomy remains the definitive diagnostic test when suspicion persists despite negative studies. Diagnostic peritoneal lavage may reveal blood, bile, or bowel contents but has a false-negative rate of up to 65%.
Differential Diagnosis
Hollow viscus injuries involving stomach or intestines, liver and biliary injuries, vascular injuries including aortic or mesenteric vessels, and postoperative complications such as infection or suture dehiscence.
Treatment Pre Hospital
Follow standard trauma protocols. Clear documentation of mechanism of injury and transport to an appropriate trauma center are essential.
Initial Stabilization And Therapy
Secure the airway and initiate resuscitation as needed. Provide aggressive fluid resuscitation with warmed crystalloids and transfuse blood products when indicated. Place central venous access in unstable patients. Initiate nasogastric decompression and obtain early trauma surgery consultation.
Emergency Department Treatment And Procedures
Administer tetanus prophylaxis and broad-spectrum antibiotics for penetrating injuries. Definitive management typically requires laparotomy with duodenal exploration. Low-grade blunt injuries (grade I or II) are often managed nonoperatively, though up to 10% may fail conservative therapy. Antibiotics are essential in cases of perforation to prevent sepsis.
Medication
Cefoxitin 2 g IV every 6 hours (pediatric dose 40 mg/kg) or levofloxacin 750 mg IV or ciprofloxacin 400 mg IV daily combined with metronidazole 500 mg IV every 8 hours.
Follow-Up And Disposition
All patients with duodenal injury require admission to a trauma surgical service. Minor hematomas may require nasogastric decompression for obstruction for up to seven days with close observation for expansion or rupture. No patient with confirmed duodenal trauma should be discharged from the emergency department. Complications include intra-abdominal abscess, duodenal fistula, pancreatic fistula, and sepsis.
Issues For Referral
Duodenal injuries are graded using the American Association for the Surgery of Trauma Duodenal Injury Scale, with most injuries being grade II or III. Approximately 80% are managed with primary repair.
Follow-Up Recommendations
All confirmed injuries require inpatient management. If diagnostic studies are negative, arrange follow-up with a primary care physician within 24–48 hours. Begin with clear liquids and advance diet as tolerated.
Pearls And Pitfalls
Delayed or missed diagnosis significantly increases morbidity and mortality. Physical examination may be misleading due to the retroperitoneal location of the duodenum. Persistent clinical suspicion warrants immediate surgical consultation even with negative diagnostic tests.
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