Rosen & Barkin's 5-Minute Emergency Medicine Consult (225 page)

BASICS

• 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
  

• 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

• Complaints may be minimal with vague abdominal, flank, and back pain
  
• High GI obstruction may be seen with duodenal hematomas
  

Penetrating or blunt abdominal trauma

• Retroperitoneal: Often subtle, RUQ pain, nausea, vomiting, tachycardia, fever
  
• Intraperitoneal: Peritonitis
  

• Basic labs including amylase
  
• Acute abdominal series or CT
  
• Diagnostic peritoneal lavage (DPL) or ex lap if unstable, high suspicion
  

• 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 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
    

• 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)
    

• 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

• Follow trauma protocols
  
• Important to have pre-hospital personnel provide clear description of mechanism of injury and to transport to appropriate facility
  

• 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
  

• 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
  

• 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

• 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:
  

• Majority injuries Grade II or Grade III
  
• 80% primary repairs
  

• 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
  

• 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
  

• 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.
  

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