Tag Archives: duodenum

Pop Quiz – Final Answer

Here’s some background info to go with the xray presented Wednesday:

  • Thin
  • Athlete
  • Epigastric trauma

Put these three together and you get a patient engaged in significant physical activity who was struck in the abdomen. If no pads are involved in the sport, the patient has little padding of their own.

This is a setup for pancreatic or duodenal trauma. This patient presented after being struck in the epigastrium by an elbow during a soccer game. It hurt, but wasn’t bad enough to stop playing. The following day, she was a little sore but felt bloated and started throwing up after breakfast.

In the ED, a CT was obtained. Here is a coronal view showing the distended stomach:

Axial views showed obstruction in the proximal 3rd portion of the duodenum, right over the spine:

An (unnecessary) contrast study was performed, which confirmed the pathology. Note the tapering and corkscrew appearance of the duodenal folds.

 

Final diagnosis: duodenal hematoma. This is a crushing injury from compression of the anterior abdominal wall against the spine. The third portion of the duodenum lies over the spine, as does the pancreas, so both are likely to be injured. The latter organ appeared normal on the CT.

Management of blunt duodenal hematoma is simple: wait on it. These will generally resolve quickly over the course of a few days. NG decompression is mandatory, since nothing will pass the obstructed area (saliva, gastic juice, and pancreatic effluent, which add up to 2L+ of fluid per day). In rare cases, parenteral nutrition may be needed if resolution time is approaching the one week mark or in smaller children. A surgical approach with drainage of the hematoma has a low but significant morbidity compared to just waiting. Athletes may return to play soon after recovery.

Blunt Duodenal Injury In Children

Blunt injury to hollow organs is rare in adults, but a little more common in children. This is due to their smaller muscle mass and the lack of protection by their more flexible skeleton. Duodenal injury is very rare, and most trauma professionals don’t see any during their career. As with many pediatric injuries, there has been a move toward nonoperative management in selected cases, and duodenal injury is no exception.

What we really need to know is, which child needs prompt operative treatment, and which ones can be treated without it? Children’s Hospital of Boston did a multicenter study of pediatric patients who underwent operation for their injury to try to tease out some answers about who needs surgery and what the consequences were.

A total of 16 children’s hospitals participated in this 4 ½ year study. Only 54 children had a duodenal injury, proven either by operation or autopsy. Some key points identified were:

  • The injury was very uncommon, with one child per hospital per year at best
  • 90% had tenderness or marks of some sort on their abdomen (seatbelt sign, handlebar mark, other contusions). 
  • Free air was not universal. Plain abdominal xray showed free air in 36% of cases, while CT showed it only 50% of the time. Free fluid was seen on CT in 100% of cases.
  • Contrast extravasation was uncommon, seen in 18% of patients.
  • Solid organ injuries were relatively common
  • Amylase was frequently elevated

Although laparoscopic exploration was attempted in about 12% of patients, it was universally converted to an open procedure when the injury was confirmed. TPN was used commonly in the postop period. Postop ileus was very common, but serious complications were rare (wound infection <10%, abscess 3%, fistula 4%). There were 2 deaths: one child presented in extremis, the other deteriorated one day after delayed recognition of the injury.

Bottom line: Be alert for this rare injury in children. Marks on the abdomen, particularly the epigastrium, should raise suspicion of a duodenal injury. The best imaging technique is the abdominal CT scan. Contrast is generally not helpful and not tolerated well by children. Duodenal hematoma can be managed nonoperatively. But any evidence of perforation (free fluid, air bubbles in the retroperitoneum, duodenal wall thickening, elevated serum amylase) should send the child to the OR. And laparotomy, not laparoscopy, is the way to go.

Related posts: Personal case – duodenal injury in a child

Reference: Operative blunt duodenal injury in children: a multi-institutional review. J Ped Surg 47(10):1833-1836, 2012.

What’s The Diagnosis #1?

Okay, time for the answer. This 12 year old crashed his moped, taking handlebar to the mid-epigastrium. Over the next 3 days, he felt progressively worse and finally couldn’t keep food down.

Mom brought him to the ED. The child appeared ill, and had a WBC count of 18,000. The abdomen was firm, with involuntary guarding throughout and a hint of peritonitis. The diagnosis was made on the single abdominal xray shown yesterday. A closeup of the good stuff is above.

Emergency docs, your differential diagnosis list with this history is a pancreatic vs a duodenal injury based on the mechanism.

Classic findings for duodenal injury:

  • Scoliosis with the concavity to the right. This is caused by psoas muscle irritation and spasm from retroperitoneal soiling by the duodenal leak.
  • Loss of the psoas shadow on the right. Hard to see on this xray, but the left psoas shadow is visible, the right is not. This is due to fluid and inflammation along this plane.
  • Air in the retroperitoneum. In this closeup, you can actually see tiny bubbles of leaked air outlining the right kidney. There are also bubbles along the duodenum and a few along the right psoas.

We fluid resuscitated first (important! dehydration is common and can lead to hemodynamic issues upon induction of anesthesia) and performed a laparotomy. There was a  blowout in the classic position, at the junction of 1st and 2nd portions of the duodenum. The hole was repaired in layers and a pyloric exclusion was performed, with 2 closed drains placed in the area of the leak.

The child did well, and went home after 5 days with the drains out. Feel free to common or leave questions!

To see the full-size abdominal xray, click here.