Management of traumatic duodenal hematomas in children

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

Duodenal Trauma in Children: What is the Status of Non-Operative Conservative Treatment?

Conservative treatment of duodenal trauma in children has long been the first line of treatment for duodenal wall hematomas. However, it has rarely been described in duodenal perforations. Our purpose is to highlight the possibility of conservative treatment in selected cases of duodenal perforation. In the period between 2009 and 2022, 6 children were treated for duodenal injury following abdominal blunt trauma in the pediatric surgical emergency department. The clinical presentation, diagnosis and treatment are reported and analyzed. Three patients presented with duodenal hematomas, they were treated non-operatively with hospital stays between 12 and 20 days and good clinical outcome. One child presented with duodenal hematoma and retroperitoneal air bubbles; non-operative conservative treatment was carried with favorable results. The fifth patient had a duodenal perforation; he underwent a primary duodenal 2-layers closure. The last patient had a combination of duodenal hematoma and perforation involving 75% of the duodenal diameter for which he underwent a gastro-jejunostomy with pyloric exclusion. An isolated duodenal lesion can be subject to a conservative treatment whenever allowed by a stable clinical condition and the availability of appropriate clinical and radiological monitoring.

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries

OBJECTIVE

The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children.

METHODS

Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21 years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted.

RESULTS

A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7 ± 3.3 years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0 ± 3.3 years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported.

CONCLUSION

Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

Duodenal hematoma in pediatric age: a rare case report

In pediatric age, duodenal hematoma is rare and generally occurs following a closed abdominal trauma due to the crushing of the duodenum against the rigid plane of the spine; it rarely follows anticoagulant therapy, pancreatitis, bleeding disorders, vasculitis, tumors or upper digestive endoscopy. Duodenal hematoma is a rare cause of obstruction of the upper gastrointestinal tract and acute pancreatitis, and the diagnosis is sometimes difficult and late. On the other hand, the identification of the pathology in its initial stages allows the young patients to be subjected to a conservative treatment that resolves the issue most of the time, thus avoiding surgery. In this article we describe an unusual case of duodenal hematoma, following esophagus-gastro-duodenoscopy, in a 12-year-old boy with Di George syndrome.

Conservative management of traumatic acute intramural hematoma of duodenal 2nd and 3rd portion: A case report and review of literature

Traumatic intramural duodenal hematoma (IMDH) is a rare disease occurring usually in children. The treatment modality of traumatic IMDH varies according to clinical manifestations. We had a case of a young man who had traumatic IMDH and treated nonoperatively. He had 3 weeks of conservative care and has been discharged, with follow up abdominal CT scan showing complete resolution of the hematoma. In conclusion, patient with traumatic acute intramural hematoma of duodenal 2nd and 3rd portion have excellent clinical outcomes with conservative therapy.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Evolution of intramural duodenal hematomas on magnetic resonance imaging

BACKGROUND

The magnetic resonance imaging (MRI) characteristics of evolving duodenal hematomas in children are unknown.

OBJECTIVE

To describe the MRI changes exhibited by evolving duodenal hematomas and the likely mechanisms behind these changes.

MATERIALS AND METHODS

We retrospectively reviewed the MR features of intramural duodenal hematomas (6 lesions, 10 examinations) studied on a 1.5-T MR unit. All patients had clinical histories of blunt abdominal trauma or endoscopic procedures and we were able to determine the time interval between the onset and MR imaging. We evaluated and analyzed the appearance and signal intensity patterns of hematomas of varying ages and we compared the results with those in previously reported intracranial hematomas.

RESULTS

The imaging appearances on five examinations were consistent with presence of deoxyhemoglobin. Two of these lesions were hypointense on T2-weighted images and iso- to hyperintense on T1-weighted images. Three had heterogeneous appearances on both T1- and T2-weighted images, and the bulk of the hematoma progressively increased in size and signal intensity on T2-weighted images. On the remaining five examinations, one lesion was hyperintense on T1-weighted images and iso- to hyperintense on T2-weighted images, consistent with intracellular methemoglobin, and four lesions were hyperintense on both T1- and T2-weighted images, consistent with the presence of extracellular methemoglobin. Duodenal hematoma stages were slower than those of intracranial hematomas; the acute stage spanned 2-7 days, and early and late subacute stages occurred 10-17 days after the injury.

CONCLUSION

Duodenal hematomas evolve like intracranial hematomas, but slower. Signal heterogeneity is common in the acute stage.

Ultrasound assessment of the bowel: inflammatory bowel disease and conditions beyond

Ultrasound (US) is a versatile imaging study for the evaluation of the bowel in children. US imaging of the bowel can be used as the initial examination or in follow-up for many common pediatric diseases. In this article, we highlight our bowel US technique and describe how US can depict the features of a select group of bowel pathologies relevant to pediatric practice.