Duodenal Trauma

Duodenal Trauma is a topic covered in the 5-Minute Emergency Consult.

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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 first section
    • Lies primarily over first 3 lumbar vertebrae
    • Second 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
    • Mortality occurs in 15–20%
    • Late mortality usually from sepsis

Pediatric Considerations
  • Majority secondary to recreational injuries (e.g., 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 first 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

  • 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 (MVC, assault, handlebar injury)
  • Penetrating trauma:
    • Most common cause of injury
    • Creates cavitations, can lead to infection

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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 first section
    • Lies primarily over first 3 lumbar vertebrae
    • Second 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
    • Mortality occurs in 15–20%
    • Late mortality usually from sepsis

Pediatric Considerations
  • Majority secondary to recreational injuries (e.g., 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 first 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

  • 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 (MVC, assault, handlebar injury)
  • Penetrating trauma:
    • Most common cause of injury
    • Creates cavitations, can lead to infection

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