Obstructing Intramural Duodenal Hematoma Following Relatively Minor Trauma in a Child: A Report of a Case Managed Surgically and Discussion of Relevant Treatment Options

摘要

Injuries to the duodenum are uncommon due to its retroperitoneal location, although not rare. They represent approximately 3-5% of abdominal injuries. Duodenal injury secondary to blunt trauma continues to pose a diagnostic challenge. We report a case of a 13-year-old female with duodenal hematoma and we review the literature to evaluate the cause, radiologic findings and operative versus non-operative management.A 13-year-old female presented to the emergency department referred from an outside clinic. The child ran into a chain-link fence 2 days prior. She developed abdominal pain, nausea and vomiting which persisted. A CT scan showed a large hematoma in the third portion of her duodenum. She was started on bowel rest and nasogastric suctioning. But even after 2 hours, her nasogastric output continued to be high and there was no resolution of the symptoms or size of the hematoma. She underwent a diagnostic laparoscopy which was converted to an exploratory laparotomy with evacuation of duodenal hematoma, repair of duodenotomy and repair of SMV venotomy. Her recovery was unremarkable.Prompt diagnosis and treatment of blunt duodenal injury (BDI) is crucial, with evidence suggesting that a delay in diagnosis and treatment of more than 24 hours after injury can increase mortality from 11% to 40%. Duodenal hematomas result from compression of the duodenum against the vertebral column, whereas perforations potentially develop from shearing forces or from simultaneous closure from the pylorus and the fourth part of the duodenum, resulting in increased intraluminal pressure and a blowout. In addition, associated intra-abdominal injuries (pancreas, spleen, liver, and kidney) are common and usually determine overall mortality and morbidity.Treatment of BDI depends on the extent and severity of bowel injury and the presence or absence of perforation. The majority of duodenal hematomas can be managed non-operatively, evidence of duodenal perforation requires surgical exploration. The majority of perforations in children were managed with simple surgical techniques with 80% undergoing primary repair (duodenorrhaphy). The majority of injuries were secondary to motor vehicle collisions. Pancreatic injuries were commonly associated. Early diagnosis is critical as was demonstrated by Lucas and Ledgerwood in 1975. Mortality for BDI treated within 24hours was 11%, compared with a rate of 40% if delayed for more than 24hours. Interval from injury to operation is the most important risk factor determining the incidence of morbidity and mortality. Currently, computed tomography with intravenous contrast is the diagnostic test of choice in stable patients with blunt abdominal trauma. The presence of retroperitoneal extraluminal air on CT is an important sign of BDI requiring surgical repair. The use of the duodenal Organ Injury Scale will facilitate the surgical management of these injuries, and the development of protocols. Introduction Traumatic intramural duodenal hematoma (IDH) in children occurs in 2 to 3% of blunt abdominal trauma (1,2). Anatomic factors such as duodenal retroperitoneal fixation, position in front of the vertebral column, the rich submucosal and subserosal vascular plexus, and a weak muscular abdominal wall, are all contributory to the development of IDH. The close duodenopancreatic relationship explains why traumatic pancreatitis is the most commonly associated intraabdominal injury in IDH. Jewett et al. (1), in a revision of 182 cases of IDH in children, found that 21% had associated pancreatitis.The responsible blunt abdominal trauma is at times so trivial that in many occasions the child cannot remember it (3). Handlebar trauma, road traffic injury and sports trauma are the common etiologic factors (4,5). In addition, child abuse should always be kept in mind, mainly in children under the age of 5 (6,7). Clotting disorders represent an additional factor that can be a cause for the development of IDH even with minimal or e