Suhair Al-Saad, CABS, FRCSI
Rani Al-Mutaz, FRCSI
Thirty-six years old Bangladeshi male was involved in RTA. He was admitted through A/E complaining of upper abdominal pain and vomiting. The mechanism of injury was direct blow to the upper abdomen by the steering wheel.
Abdominal examination revealed abrasions, tenderness and guarding upper abdomen. No abdominal distension. Blood tests were within normal ranges.
Few hours later the patient became
febrile, pale and the NG tube was draining coffee ground fluid. Abdominal
examination revealed generalized tenderness and guarding. CT scan
of the abdomen was done and report was normal.
Q1. What is your clinical impression?
Q2. What is your next investigation?
Q3. Describe the radiological findings you see?
Q4. What is your plan of
management?
Answers to Medical Quiz
A1. Rupture or perforation of a hollow viscus.
A2. Gastrografin (water-soluble dye study).
A3. Significant leak of
contrast from the third part of the duodenum with
submucosal edema or hematoma.
A4. Surgical closure of the perforation.
DISCUSSION
Duodenal injuries remain relatively rare with an incidence of 1-17% in blunt abdominal trauma and 1.7-5% in penetrating injuries1,2. Mortality rate is reported to be of approximately 60% and is related directly to the difficulty in early diagnosis and severity of associated injuries especially when combined with pancreatic injuries. The cause of injury is generally a direct blow to the upper abdomen.
The delay in diagnosis is due to its retroperitoneal location, neutral PH and a low bacterial count leading to no or little early chemical or bacterial retroperitonitis respectively. Early diagnosis depends on high suspicion of the condition in patients who receive a blow to the upper abdomen or lower chest. Plain abdominal X-rays may show classical signs of rupture which include retroperitoneal air and obliteration of the upper right psoas muscle shadow3,4. Injection of water-soluble radiological dye through NG tube to see clearly the extravasation of the dye. CT scan in combination with oral contrast is also quite accurate.
Treatment options include closure,
diversion or resection procedures depending on the time of diagnosis, patient’s
haemodynamic status. The extent and location of the
injury and the presence or absence of concomitant injury to the pancreas. The major complication of duodenal repair is a duodenal fistula.
REFERENCES
1.Poostizadeh A. Traumatic
perforation of duodenal diverticulum. J Trauma
1997;43:370-1.
2.Shilyansky J. Diagnosis
and management of duodenal injuries in children. J
Pediatric Surg
1997;32:880-6.
3. Cox MR. Traumatic duodenal
rupture and avulsion of the ampulla of Vater. HPB
Surg
1994;7:225-9.
4.Riedl S. Effect of
diagnostic imaging techniques on choice of therapy and
prognosis of traumatic
pancreas and duodenal injuries. Langenbecks Arch Chir
1994;379:38-43.
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* Consultant General
Surgeon
** Senior Surgical Resident
Department
of Surgery
Salmaniya
Medical Complex
Ministry
of Health
Kingdom
of Bahrain
