Delayed perforation of a duodenal diverticulum by a biliary endoprosthesis

A 73-year-old woman with cholangitis due to stricture of the bile duct and the presence of stones was treated by the placement of a biliary endoprosthesis. However, 8 weeks later the lower end of the stent had retracted into a duodenal diverticulum and penetrated its inferior wall. The patient was readmitted to hospital for treatment of a retroperitoneal abscess.

[Traumas of the duodenum]

The aim of this study is to present current management of duodenal trauma. Duodenal lesions following penetrating injuries are rare, but more serious, than those following blunt injuries. the severity is mostly due to delay in the diagnosis and associated intraabdominal injuries. Diagnosis is based on abdominal plain film, gastroduodenography, and more recently US scan and CT-scan. Surgical procedures depend on the type of lesion. In patients operated early, a duodenal wound can be treated by suture-closure with duodenal decompression tube. If suture-closure is not available, with a wound affecting proximal or distal duodenum, resection with anastomosis can be performed. In the second portion of the duodenum, the best treatment is a jejunal plasty with a Roux-en-Y loop. When there is an associated pancreatic injury, treatment depends on whether biliary or pancreatic ducts are injured, and a pancreatico-duodenectomy could be necessary. In patients operated on later, closure with duodenal exclusion by diverticulization is associated due to the high risk of leaking.

[Duodenal perforation following endoscopic papillotomy: report of 3 cases]

Duodenal perforation is a rare complication of endoscopic sphincterotomy and its treatment is controversial. The authors report three cases of duodenal perforation by endoscopic sphincterotomy. In two cases with history of a previous biliary infection, surgical treatment had to been performed because of a peripancreatic abscess.

Isolated bowel injury in blunt abdominal trauma in childhood

From a total of 734 children with a blunt abdominal trauma admitted to the hospital in the past 15 years, 21 patients (3%) sustained an isolated injury of the bowel (8 duodenal, 9 jejunal and 4 colon ruptures). All patients were laparotomized without a postoperative mortality. Accompanying abdominal injuries were seen only in duodenal ruptures (pancreatitis and one choledochal and pancreatic ruptures). In 85% the blunt violence was caused by bicycle accidents due to the handle bar, in one case by a car accident and in 3 children by falls. Accurate diagnosis was only possible regarding the history, the mechanism of the accident and an exact repeated clinical examination. Despite further investigations of blood chemistry laboratory findings, ultrasound and x-ray, no further confirmation of the diagnosis could be achieved. Complications, occurring in 14% of our patients, were not related to the trauma itself, but caused by a delayed diagnosis and therapy.

Duodenal perforation after laparoscopic cholecystectomy

A case is reported of duodenal perforation complicating laparoscopic cholecystectomy performed by laser dissection. The importance of investigating a patient with persistent shoulder-tip pain following this technique to exclude a subphrenic abscess is emphasised.

Rupture of the duodenum with avulsion of the papilla of Vater due to blunt trauma in a child, and review of the literature

Duodenal rupture with avulsion of the papilla of Vater is an uncommon injury due to blunt abdominal trauma in children. This report describes a 9-year-old boy who sustained this injury and was treated successfully two days delayed by a Roux-en-Y choledocho-pancreaticojejunostomy and temporary implantation of a zipper for abdominal wall closure. The rarity of this complex injury and its initial presentation as a posttraumatic pancreatitis warrant its description. A review of the literature, modes of diagnosis and surgical technique for repair are described.

Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.

Cholelith causing duodenal obstruction in a horse

A 10-year-old Appaloosa stallion was referred for evaluation of colic. At admission, the heart rate, capillary refill time, respiratory rate, and rectal temperature were high. Fifteen liters of reflux was obtained by nasogastric intubation. Palpation of an abdominal mass per rectum elicited signs of pain. At exploratory laparotomy, a mass was palpated in the ascending portion of the duodenum. The small intestine ruptured at the site of obstruction during manipulation. The horse was euthanatized. A large cholelith was the cause of the duodenal obstruction. At necropsy, multiple choleliths of various sizes were found in the pancreatic and common bile ducts and in the stomach.

Computed tomography of retroperitoneal duodenal rupture in blunt abdominal trauma

Two cases of retroperitoneal duodenum rupture following an upper abdominal blunt trauma are reported. Computed tomography (CT) demonstrates at best extraintestinal fluid and air in the retroperitoneum, especially if acquisition in right lateral decubitus is possible. Drawbacks of the method are also reviewed.

Early roentgen diagnosis of retroperitoneal duodenal rupture due to blunt abdominal trauma

Retroperitoneal duodenal rupture due to blunt abdominal trauma is relatively uncommon. Diagnosis is difficult because the physical signs are subtle or they are difficult to interpret. A case of retroperitoneal duodenal rupture due to blunt abdominal trauma in whom the diagnosis was delayed is reported. Radiographic features are discussed. The role of early roentgen diagnosis is stressed in order to reduce the very high mortality which is associated with delay in diagnosis and treatment.

Duodenal rupture with avulsion of the bile duct: an unusual injury

Blunt abdominal trauma may give rise to infrequent and unusual patterns of organ damage requiring prompt and complete exploratory laparotomy if the full extent of injury is to be recognised. We present a case of avulsion of the common bile duct in association with duodenal rupture to illustrate the importance of this strategy.

A rare complication due to sulfuric acid ingestion

The authors present a case of pyloric and duodenal obstruction in an 8-year-old child, resulting from accidental ingestion of sulfuric acid. A marked pyloric and duodenal cicatrizing stenosis resulting from ingestion of sulfuric acid is seen infrequently, especially in pediatric age. Sulfuric acid produces a coagulation necrosis of the gastric mucosa and submucosa, and the process may involve the entire thickness of the gastric wall, with subsequent ulceration and fibrosis. This dynamic pathophysiologic event imposes postponement of surgical intervention because of various time length between ingestion of acid and onset of gastric outlet obstruction (17 days to 5 years). Clinical features included postprandial epigastric distress, repeated non-bilious vomiting, and marked weight loss. The authors also discuss the various surgical procedures that were employed to relieve the obstruction. Notwithstanding a potential risk of malignant evolution, a gastro-jejunostomy is the treatment of choice because of the age of the patient, and good postoperative results are confirmed by barium studies.

[A difficult diagnosis: retroperitoneal rupture of the duodenum caused by closed trauma of the abdomen]

The Authors report two cases of sub-peritoneal rupture of the duodenum following blunt abdominal trauma. The diagnostic difficulties are explained in detail. Emphasis is placed on the importance of prompt recognition of the duodenal injury and early surgical treatment to ensure a successful outcome.

The injured duodenum

Duodenal injuries are relatively infrequent. A high index of suspicion is required because the retroperitoneal location of the duodenum makes the diagnosis of injuries difficult. Physical findings may be subtle and nonspecific. Contrast studies are often required to make the diagnosis. Options for operative management are outlined. Morbidity and mortality are related to associated injuries and delay in diagnosis.

Aspergillus flavus wound infection following repair of a ruptured duodenum in a non-immunocompromised host

Aspergillus flavus is generally considered to be an opportunistic organism, rarely causing clinical infections in the immunocompetent host. We present a case of a 79-year-old man without history of immunocompromise who developed a severe aspergillus wound infection in an open wound following repair of a traumatic duodenal perforation. Despite aggressive treatment, this invasive infection contributed significantly to his eventual demise.

Current management of trauma to the pancreas

This review examines pancreatic trauma and its management in the light of recent experience. The incidence, mechanism, classification, diagnosis, treatment and complications of pancreatic trauma are discussed. The difficulty in establishing the diagnosis is addressed and possible solutions are provided. The case for conservative surgery in the absence of pancreatic duct damage is outlined. The importance of draining all pancreatic injuries is emphasized.

[Lesions of the duodenum from closed abdominal injury. A case report]

Following a review of the literature, the paper reports a case of duodenal injury. This rare pathology most frequently affects the second half of the organ and may cause damage ranging from a simple hematoma to parietal laceration with peritonitis and/or retroperitonitis. Symptoms are often confusing and delayed, and together with chemical and instrumental tests do not always allow an early diagnosis to be made. Treatment varies according to the type of lesion and its location, and is often secondary to the general condition of the patient. Postoperative mortality appears to be limited to 11% if laparatomy is performed early (within 24 hours).

Conservative surgery for trauma to the pancreatic head: is it safe?

The results of conservative operative management (involving no pancreatic resection) for 13 patients presenting with trauma to the pancreatic head over a period of 10 years were reviewed. Seven patients with injury of the pancreatic head without duodenal or ductal involvement made an uneventful recovery after simple drainage. The average hospital stay was 6.7 days. The remaining six patients with either duodenal (four patients) and/or ductal involvement (five patients) developed 22 major complications. One of these patients died of multiple organ failure, and the rest had an average hospital stay of 43 days. Injury of the vena cava was noted in five patients, but was not significantly associated with additional morbidity or mortality. Although simple drainage of pancreatic head injuries is associated with a low mortality, there is an unacceptably high incidence of complications if either the duodenum or pancreatic duct is involved. The authors recommend that simple drainage be restricted to patients in whom neither of these structures is injured.

Management of duodenal injuries by proximal T-tube drainage

Duodenal injuries may be caused by blunt or penetrating trauma. There is a high mortality rate with this type of injury, particularly when associated with pancreatic trauma. The surgical management of such injuries is difficult and a technique is described which may reduce postoperative morbidity, as illustrated by the two cases described.