Duodenal Injuries

Traumatic duodenal and pancreatic injuries occur in ~3-5% of patients with abdominal trauma. The clinical diagnosis of a duodenal injury can be difficult given that the majority of the organ is located in the retroperitoneum.
 

The duodenum is 20 cm long and consists of 4 segments, most of which lay directly over the spinal column. The 1^st segment of the duodenum begins at the pylorus and extends to the common bile duct and gastroduodenal artery. The 2^nd portion extends to the ampulla of Vater while the 3^rd portion runs transversely to the superior mesenteric artery and vein. The 4^th portion extends to the ligament of Treitz, where the small bowel transitions into the jejunum.

Approximately 75-85% of blunt duodenal injuries are the result of motor vehicle collisions, occurring when the primarily fixed organ is crushed between the spinal column and a seat belt or steering wheel. Gunshot wounds rather than stab wounds are more likely to be the cause of penetrating trauma to the duodenum.

The most commonly used injury classification scale is from the AAST.

 

Grade I: Hematoma involving a single portion of the duodenum OR partial thickness laceration without perforation

Grade II: Hematoma involving more than one portion OR disruption <50% circumference OR major laceration without ductal injury or major tissue loss

Grade III: Disruption of 50-75% circumference of 2^nd portion OR disruption of 50-100% of 1^st/3rd/or 4^th portion

Grade IV: Disruption of >75% circumference of 2^nd portion OR injury involving the ampulla or distal common bile duct

Grade V: Massive laceration with disruption of the duodenopancreatic complex or devascularization of the duodenum

 

Non-operative management consisting of gastric decompression and IV nutritional support can be attempted in patients with grade I-II blunt injuries. Non-operative management of penetrating duodenal injuries have not been reported. A significant number of patients undergoing exploratory laparotomy for other abdominal injuries will be found to have duodenal or pancreatic injuries. Therefore, visible areas of the retroperitoneum should be inspected for bile staining, entrapped air bubbles, and peri-duodenal or peri-pancreatic hematomas. If there is a high suspicion for injury, the retroperitoneum should be formally examined.

 

Partial thickness injuries can be repaired by suturing the serosa in a Lembert fashion. Grade II lacerations can usually be debrided and primarily repaired; longitudinal injuries should be closed transversely to minimize stricture formation. More extensive injuries that do not involve the 2^nd portion of the duodenum may be treated with a segmental resection and a primary end-to-end duodenoduodenostomy. With injuries that do involve the 2^nd portion of the duodenum and the ampulla, management becomes more complex and involves drainage and possible pyloric exclusion procedures.

 

References:

1. Up-to-Date: Management of duodenal and pancreatic trauma in adults.

2. Moore EE, et al. Organ injury scale, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma, 1990; 30(11): 1427.

3. Degiannis E, et al. Duodenal injuries. Br J Surgery, 2000; 87: 1473-79.

 

This post submitted by Dr. Andrea Olivas