Management of isolated duodenal rupture due to blunt abdominal trauma: case series and literature review

Isolated duodenal perforation in children: Importance of high index of suspicion following blunt trauma abdomen

Introduction

Isolated duodenal perforation (IDP) is rare and only isolated cases are reported in the literature. Due to its rarity and subtle presentation, the diagnosis of IDP is often delayed. Delay in the diagnosis and surgical intervention result in increased morbidity and mortality. The aim of this article is to highlight the importance of a high index of suspicion of IDP following blunt abdominal trauma and safety of primary repair without diversion in such cases.

Material and methods

Children with isolated duodenal injuries following blunt abdominal trauma were included; mode of trauma, clinical presentation, diagnosis, operative intervention and outcome were studied.

Results

Nine patients with isolated duodenal perforations were identified and operated on. Most had minimal clinical findings on arrival and were haemodynamically stable. Abdominal radiography and ultrasonography were unremarkable. However, pain remained persistent and worsening of vomiting was seen over time. Contrast-enhanced computed tomography (CECT) of the abdomen with oral and intravenous contrast was done to identify the injuries. Primary repair of perforation was performed in all cases. The most common cause was road traffic accident. There were three Grade 2 injuries, five Grade 3 and one Grade 4 injuries. Eight patients healed well with uneventful recovery – one patient died from sepsis after presenting 24 h after injury with frank peritonitis.

Conclusion

Isolated duodenal perforation presents without specific signs and symptoms and a high index of suspicion is necessary for early diagnosis. Contrast-enhanced computed tomography of the abdomen with oral contrast should be ordered early if symptoms persist or worsened over time.

A case of pediatric duodenal transection caused by abuse successfully treated by duodenojejunostomy

Background

Abuse can be a cause of pediatric duodenal injury. Patients who have been injured by abuse tend to have delay before medical examination, they may therefore have especially poor prognosis.

Case presentation

A 3‐year‐old boy presented with abdominal pain and was diagnosed with duodenal perforation. He was urgently transferred to our hospital for surgery. There was no clear history of trauma according to initial parent interviews, but old bruises were observed in several places. Paternal remarks about the injury mechanism were contradictory to bruit findings. Eventually, the mother reported daily paternal domestic violence against the patient. Duodenal perforation was considered to be caused by physical abuse, and emergent surgery was carried out. Intraoperative findings revealed transection at the horizontal part of the duodenum. Primary repair was difficult due to severe damage, so duodenojejunostomy was undertaken.

Conclusion

Duodenojejunostomy was successfully carried out as emergent surgery for severely damaged duodenal transection.

Paediatric duodenal injury complicated by common bile duct rupture due to blunt trauma: a multispecialist approach

We report a case of late presenting duodenal perforation with common bile duct rupture secondary to blunt handlebar trauma in an 11-year-old boy. The patient presented with upper abdominal wall ecchymosis, pain and vomiting. He was discharged after 24 hours with resolving symptoms. However, the boy presented 2 days later febrile with signs of peritonitis. CT indicated duodenal perforation, which was confirmed during laparotomy where common bile duct rupture was also demonstrated. Primary repair of the duodenum was undertaken. Here, decompression was achieved with a nasogastric tube proximal to the injury and T-tube duodenostomy distally. Common bile duct repair was achieved over a biliary stent. This case represents a rare subset of duodenal injury for which there is a paucity of evidence for optimal surgical management, particularly in the paediatric setting. This operative plan will guide surgeons and junior doctors in managing complicated cases like this in future.

An isolated duodenal perforation in pediatric blunt abdominal trauma: a rare but distinct possibility

Isolated duodenal perforation (IDP) in pediatric trauma is rarely reported. Since most of the children with blunt trauma are managed expectantly, timely diagnosis is imperative to avoid morbidity and mortality. We report a case of IDP and emphasize on certain specific clinical features indicating possibility of duodenal injury. We also stress upon the role of early contrast-enhanced computerized tomography (CECT) in such cases.