Clinical History
A 30 year old male driver was admitted to the hospital after a high-speed motor vehicle collision.
Imaging Findings
A 30 year old male driver was admitted to the hospital after a high-speed motor vehicle collision. At admission, he was awake and alert with stable vital signs. He complained of diffuse abdominal pain, mainly localized over an abrasion on the right upper quadrant. Abdominal roentgenograms were normal.
His blood pressure, pulse rate, and body temperature were within normal limits. The laboratory test results were also normal. Clinical examination showed mild tenderness in the RUQ.
CT findings included haziness of the limits with possible discontinuation of the duodenal wall at the 1st and the 2nd portion of the duodenum. The 3rd portion showed moderate wall thickening. Increased attenuation of local omental fat was also noted.
Liver lacerations at the hilum and at segment VI were noted, accompanied by the presence of air bubbles at the liver hilum, the anterior liver surface and the gallbladder fossa. There was presence of free fluid collection in the periduodenal area extending in the perihepatic space, Morrison’s pouch, right paracolic recess and Douglas pouch.
Surgery confirmed rupture of the anterior wall of the duodenal bulb along with the presence of intraperitoneal gastric content and a small amount of free intraperitoneal bile. The lesion was treated with duodenorrhaphy plus drainage. Liver contusions were treated conservatively considering the fact that liver capsule appeared intact.
Discussion
Duodenum is the widest portion of the small bowel. It has no mesentery and is partially covered by the peritoneum. It is 25–30cm long and is divided into 4 sections. The first (superior) extends from the pylorus to the neck of the gallbladder and is primarily composed of the duodenal bulb. The second (descending) portion extends from the neck of the gallbladder to the genu, usually at the level of the fourth lumbar vertebra. Abnormalities in this portion are mainly due to pathologic conditions in adjacent structures, including the pancreas and biliary system. The third (horizontal) extends from the fourth lumbar vertebra to the level of the aorta and is often affected by trauma due to the retroperitoneal location and proximity to the spine. The fourth (ascending) portion extends from the aorta to the ligament of Treitz.
Duodenal trauma may result from penetrating or blunt injury. During blunt trauma, the duodenum may collide against the vertebral body, causing contusion or transaction. Duodenal perforation occurs in 2–20% of patients with blunt abdominal injury and often occurs after accidents with high-riding seat belts. Rapid deceleration in motor vehicle accidents can also result in duodenal trauma. Primary repair or duodenorrhaphy is successful in the majority of duodenal wounds. The organ’s retroperitoneal location may produce minimal and vague symptoms such as abdominal, back or flank pain with a progressive rise in temperature, tachycardia and occasional vomiting. After several hours, the duodenal contents extravasate into the peritoneal cavity, with the development of peritonitis. Pain radiating to the neck or testicles is also reported. Detection of blunt traumatic injury to the duodenum is difficult at physical examination, and the choice of treatment is dependent on whether there is a contusion or a perforation. Intramural hematoma without perforation is usually managed conservatively, but traumatic duodenal perforation is a surgical emergency. In 40% of patients with duodenal injuries, other concomitant surgically important intra-abdominal injuries such as hepatic (38%) or pancreatic (28%) injuries coexist. The death rate is reported to be up to 25% for duodenal injuries, most of the deaths are due to haemorrhage and associated injuries (liver, stomach, large vessels) and not directly related to the duodenum injury.
The second portion of the duodenum is most commonly involved (35% of the cases) followed in frequency by the third and fourth portion (15% each), whereas the first portion is wounded in only 10%. The clinical diagnosis is difficult, since peritoneal signs are frequently absent because of the retroperitoneal location of parts of the duodenum that are usually wounded. The missed early detection of duodenal perforation is associated with increased morbidity and mortality. CT is the primary imaging modality for assessment of abdominal trauma, and the diagnosis of duodenal injury should be suspected when any of the following findings are observed: (a) air adjacent to the duodenum in the retroperitoneum, (b) extravasation of oral contrast material in the retroperitoneum, (c) fluid in the retroperitoneum, (d) oedema in the duodenal wall, (e) stranding of the peripancreatic fat, and (f) pancreatic transaction.
Differential Diagnosis List
Traumatic duodenal perforation of the first portion.
Final Diagnosis
Traumatic duodenal perforation of the first portion.
