Duodenal Trauma

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 mostly over 1st 3 lumbar vertebrae
  • 2nd section is most commonly injured
• Types of injury:
  • Duodenal wall hematoma
  • Wall perforation
  • Hemorrhage, including retroperitoneal
  • Crush
• Incidence of duodenal injury is 3–5% of all traumatic abdominal injuries
• Penetrating trauma accounts for ∼75% of duodenal injuries:
  • Mortality ranges from 13–28%
  • Associated with exsanguination
• Blunt duodenal trauma has a higher mortality due to greater force of injury and often delayed diagnosis due to retroperitoneal location:
  • If injury is diagnosed in <24 hr, mortality rate is about 11%
  • If >24 hr, mortality rate approaches 40%
  • Late mortality usually from sepsis

• Majority secondary to recreational injuries (e.g., bicycle handlebar injuries)
• 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

• 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

Etiology

• Blunt trauma:
  • Shear strain: Abrupt acceleration/deceleration at point of attachment (most common retroperitoneal injury with rapid deceleration)
  • Tensile strain: Direct compression or stretching of tissue
• Penetrating trauma:
  • Most common cause of injury
  • Creates cavitations, can lead to infection