Duodenal injuries in the very young: Child abuse?

Traumatic duodenal injuries in children: a single-centre study

BACKGROUND

Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries.

METHODS

Retrospective review was conducted over a 16-year period from a single paediatric trauma centre.

RESULTS

Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified.

CONCLUSION

In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.

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.

Abuse-related trauma forward medical care in a randomly sampled nationwide population

Abuse-related trauma remains a global health issue. However, there is paucity in nationwide reports. We aim to estimate the incidence of abuse-related trauma forward medical care and identify its characteristics and clinical course in Taiwan. Patients with trauma between 2005 and 2007 that occurred 3 months before or after a diagnosis of abuse were identified from a randomly sampled nationwide longitudinal health insurance database of 1 million beneficiaries. The patients' demographic data, injury pattern, and medical resource utilization were measured, stratified by age and sex, and compared using chi-square test. Risk factors of next trauma event were identified using Cox regression analysis. Ninety-three patients (65 females) were identified (mean age, 20.6 ± 16.3 years), including 61.3% under 18 years of age. For the first trauma event, 68 patients (73.1%) visited the emergency room, 63 (67.7%) received intervention, and 14 (15.1%) needed hospital care. Seven (7.5%), all less than 11 years old, had intracranial hemorrhage and required intensive care. Thirty-three (35.5%) left with complications or sequelae, or required rehabilitation, but all survived. Of the 34 victims of sexual abuse, 32 were aged less than 18 years. Men received more mood stabilizers or antipsychotics (50.0% vs 10.7%, P = 0.030) and reeducative psychotherapy (25.0% vs 0, P = 0.044). Risk factors for a next trauma event were injury involving the extremities (hazard ratio [HR]: 5.27 [2.45-11.33]) and use of antibiotics (HR: 4.21 [1.45-12.24]) on the first trauma event. Abuse-related trauma has heterogeneous presentations among subgroups. Clinicians should be alert in providing timely diagnosis and individualized intervention.

Pediatric abdominal injury patterns caused by "falls": A comparison between nonaccidental and accidental trauma

BACKGROUND/PURPOSE

Falling from a low height is the most common history given by caregivers of pediatric nonaccidental trauma (NAT) victims evaluated for blunt abdominal trauma (BAT). The purpose of this study is to compare the patterns of injuries seen in children with BAT who are victims of NAT with those seen after a fall-related incident.

METHODS

Trauma database query from regional pediatric trauma centers identified patients were who were evaluated for BAT resulting from either NAT or a fall. Study groups included patients younger than five years who were (1) victims or NAT, or (2) fall casualties.

RESULTS

Sixty-five NATs and 115 fall casualties were identified. NAT victims had higher ISS, had more severe head injuries according to AIS scores, had more hollow viscus injuries, and had more pancreatic injuries. Fall casualties were more likely to have solid organ injuries.

CONCLUSIONS

When evaluating children with a history of blunt abdominal trauma caused by a fall, suspicion for NAT is warranted if the child is younger than five years, has a hollow viscus, pancreatic, and/or severe head injury and has a high ISS. Likewise, isolated splenic or renal injury allays suspicion for NAT.

Pancreatic and Duodenal Trauma in Children

Trauma is the leading cause of death in children of all ages. The most common site of injury in pediatric patients is the head followed by the extremities and the abdomen. Though less than 10% of admissions to the hospital are secondary to intra-abdominal injuries, mortality related to these injuries is not insignificant. Pancreatic and duodenal trauma occurs in 3 to 12% of the patients with abdominal injuries and can be associated with significant morbidity. The management of pancreatic and duodenal trauma in children is based mostly on adult data, but there is an increasing volume of research on the subject.

Role of the surgeon in non-accidental trauma

Non-accidental trauma (NAT) represents a significant cause of morbidity and mortality in the pediatric population. The management of these patients often involves many care providers including the surgeon. Victims of NAT often present with multiple injuries and as such should be treated as trauma patients with complete trauma evaluation including primary, secondary and tertiary surveys. Common injury patterns in NAT include extremity fractures, closed head injury and intra-abdominal injury. Brain imaging is of importance to rule out acute or sub-acute intracranial hemorrhage. Children under the age of 5 years with acute intracranial pathology should also be evaluated by an ophthalmologist to rule out retinal hemorrhages, which are considered pathognomonic for child abuse from violent shaking. In instances when abdominal injury is suspected, prompt evaluation by a surgeon is recommended along with CT imaging. Finding of extremity fractures should prompt evaluation by an orthopedic surgeon. At our institution, all patients with suspected NAT are admitted to the pediatric surgery service for complete evaluation and management. We encourage other pediatric trauma centers to employ a similar approach so that these complicated patients are managed safely and effectively.

Elasticity of abdominal wall vessels in children: clinical implications in child abuse

BACKGROUND

Abdominal trauma secondary to non-accidental injury is associated with high rates of morbidity and mortality. It has been noted that children who have suffered abusive abdominal injuries often lack abdominal wall bruising. We hypothesize that children have highly elastic vessels that stretch instead of rupturing when the abdomen is punched. Our study investigates the degree of elasticity in abdominal wall vessels in young children.

METHODS

Twenty children aged less than 5 years undergoing routine hernia repair or orchidopexy were included in our study. Subcutaneous vessels were identified during the procedures. The vessels were measured at resting length and when stretched to maximum length prior to rupture. Samples of the vessels were then collected for histological examination.

RESULTS

On average, we were able to stretch the vessels to 3.4 times their resting length without rupture. Histology revealed that the vessel walls contained a high amount of elastin.

CONCLUSION

We have demonstrated a high degree of elasticity in the abdominal wall vessels of young children. This may help to explain why children do not bruise when hit in the abdomen. Our findings have potential implications for both clinical practitioners and paediatric surgeons involved in child abuse cases.