Duodenal Trauma

Basics

Description

  • Characteristics of duodenum:
    • 12 in long
    • C-shaped
    • From pylorus to ligament of Treitz
    • Divided into 4 sections:
      • Last 3 sections retroperitoneal along with distal portion of 1st section
    • Lies primarily over 1st 3 lumbar vertebrae
    • 2nd section is most commonly injured (36%)
  • Types of injury:
    • Duodenal wall hematoma
    • Wall perforation
    • Hemorrhage, including retroperitoneal
    • Crush
  • Incidence of duodenal injury is 3–5% of all traumatic abdominal injuries
  • Typically damage to surrounding structures, <30% are isolated duodenal injuries
  • Penetrating trauma accounts for ∼80% of duodenal injuries:
    • Mortality ranges from 13% to 28%
    • Associated with exsanguination/ accompanying vascular injury
  • Blunt duodenal trauma has a higher mortality due to often delayed diagnosis due to retroperitoneal location and greater force of injury:
    • Mortality occurs in 15% to 20%
    • Late mortality usually from sepsis, leak of anastomosis

Pediatric Considerations

  • Majority secondary to blunt trauma (eg, bicycle handlebar impact)
  • Intramural duodenal hematomas may occur in nonaccidental trauma:
    • If suspected, prompt referral to appropriate child protective agency is required
  • In children, hematoma is most commonly seen in 1st portion of duodenum

Pregnancy Considerations

  • Retroperitoneal hemorrhage more common due to increased pelvic and abdominal vascularity
  • Large uterus serves as protection from bowel injury
  • Peritoneal irritation is blunted in the pregnant patient; therefore, greater index of suspicion is required

Etiology

  • Penetrating trauma: Most common cause of injury
  • Blunt trauma:
    • Direct compression against spine or stretching of tissue (MVC, assault, handlebar injury)
    • Crush can lead to laceration or increased intraluminal pressure leading to wall rupture
    • Shear strain from abrupt acceleration/deceleration at point of attachment (less common)

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