Case Report

Duodenal perforation following blunt abdominal

trauma
Hemanga K Bhattacharjee, Mahesh C Misra, Subodh Kumar, Virinder K Bansal
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

ABSTRACT
Duodenal perforation following blunt abdominal trauma is an extremely rare and often overlooked injury leading to
increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma and
highlight the challenges associated with their management. In both these patients, the diagnosis of the duodenal injuries
was delayed, leading to prolonged hospital stay. The first patient had two perforations, one on the anterior and the other on
the posterior wall of the duodenum, of which the posterior perforation was missed at initial laparotomy. In the other patient,
the duodenal injury was missed during the initial assessment in the emergency department. He returned to the emergency
department 24 hours after discharge with abdominal pain and vomiting. During trauma related laparotomy, complete
kocherization (mobilization) of the duodenum must be mandatory, even in the presence of obvious injury on its anterior
wall. We emphasize on keeping the management protocol simple by a triple tube decompression, i.e. duodenorrhaphy
(simple closure), tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy.

Key Words: Blunt trauma abdomen, isolated duodenal injury, triple tube decompression

INTRODUCTION CASE REPORTS

The duodenum is injured due to crushing or shearing forces Case 1

on the abdomen. It comprises 0.23.7% of all trauma related
laparotomies. The incidence of duodenal injuries is 11.226%
due to blunt trauma.[1-4] On an average, one to four other
abdominal organ injuries are associated with duodenal trauma,
which makes an isolated injury a rarity.[4,5]
The anatomical location of the duodenum makes diagnosis and
treatment of isolated duodenal injury a difficult task. Due to its
rarity and subtle clinical features, the diagnosis and management
is often delayed. We describe two patients with isolated blunt
duodenal injuries and highlight some problems and principles
in the management of duodenal injury.
Address for correspondence:
Prof. Mahesh C Misra, E-mail: mcmisra@gmail.com
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DOI:
10.4103/0974-2700.86650
514
A 14-year-old boy had a fall from a bullock cart. He was
initially managed in two private hospitals where he underwent
a laparotomy and duodenorrhaphy for traumatic duodenal
perforation 30 hours after injury. On the 6th postoperative
day (POD), he was referred to our hospital with high-grade fever,
altered mental status, abdominal distension and bilious discharge
from the laparotomy wound. Hematological investigations
revealed thrombocytopenia with features of disseminated
intravascular coagulation (DIC).
After adequate resuscitation and stabilization, the patient was
taken up for re-laparotomy. The peritoneal cavity was filled
with bilious fluid and there was crepitus along the paraduodenal
and paracolic area. The previous repair was seen intact on
the anterior wall of the second part of the duodenum. On
mobilization (Kocherization) of the duodenum, another
perforation of size 1.5cm was discovered on the posterior
wall of the second part of the duodenum. The perforation
was repaired in two layers and a triple tube decompression, i.e.
tube gastrostomy, reverse tube duodenostomy and a feeding
jejunostomy, was performed [Figure1]. An abdominal drain
was placed in the paraduodenal area and a polypropylene mesh
laparostomy was done.
Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011
 Bhattacharjee, et al.: Duodenal injury following blunt abdominal trauma

A contrast study on POD 15 showed normal passage of contrast

into the jejunum, with no leak from the injury site. Though he
had one episode of fever, he was finally discharged on POD 88
in a stable condition.

Case 2
A 21-year-old male had a fall from a scooter. He attended the
emergency department in a stable condition, and after primary
assessment, the attending physician discharged him. The patient
returned to the emergency department with abdominal pain
and vomiting 24 hours after discharge. On examination, he was
conscious, afebrile, with pulse rate 110/min and a blood pressure
of 90/60mm Hg. There was tenderness in the upper abdomen.
Serum amylase was 65 U/L (reference range 95U/L); total
leukocyte count was 11,000/mm3 (reference range 400011,000/
mm3). Plain abdominal and chest radiographs were normal. Figure1: Graphical representation of the triple tube decompression
technique (case 1) (A=tube gastrostomy, B=retrograde
Contrast-enhanced computed tomography scan of abdomen tube duodenostomy, C=feeding jejunostomy, P1=site of the
with intravenous and oral contrast media revealed free gas in perforation on the anterior wall of the duodenum, P2=site of the
the retroperitoneum, extravasation of contrast and free fluid in perforation on the posterior wall of the duodenum)
the abdomen.

The patient was taken up for emergency exploratory laparotomy.

There was bile staining and crepitus in the paraduodenal area
and nearly 200 mL of dirty fluid in the right paracolic gutter.
Complete kocherization (mobilization) of the duodenum
was done. There was a perforation in the second part of the
duodenum involving more than 50% of the circumference
[Figure2]. Duodenorrhaphy was done in two layers with
3-0 vicryl and silk sutures. A tube gastrostomy, reverse tube
duodenostomy through the proximal jejunum, and a feeding
jejunostomy and polypropylene mesh laparostomy were
performed. He was discharged home on POD 42.

Technique of mesh laparostomy

We performed a polypropylene mesh laparostomy in both
the patients, since a safe definitive closure of the abdominal
wall was not feasible due to tension and a primary closure
could have resulted in the development of an abdominal
compartment syndrome. Instead, a transparent low-cost plastic
sheath (unprinted side of a sterile urine collection bag) was
placed between the abdominal wall and the exposed viscera. An
appropriate size of a plain polypropylene mesh was then sutured
to the linea alba to cover the abdominal contents without tension.
After 48 hours, the plastic sheath was gradually removed through
the caudal end of the laparostomy. As the abdominal distension
decreased, the polypropylene mesh was divided in the midline
and gradually trimmed over several days. Each time the mesh
was trimmed, the cut edges of the mesh were re-sutured with
1-0 polypropylene suture to maintain the continuity of the mesh.
DISCUSSION
Here, we have described two patients with duodenal perforation
following blunt abdominal trauma. In both the patients, the
diagnosis was delayed. In the first patient, a second perforation
Journal of Emergencies, Trauma, and Shock I 4:4 I Oct - Dec 2011
Figure2: Photograph showing the traumatic perforation on second
part of duodenum (a), gall bladder (b). Please note the extensive
bilious staining and pus flakes all around in the retroperitoneum
was found during re-laparotomy. In the second patient, the
diagnosis was made 24 hours after the first discharge.
Diagnosis of blunt duodenal injury is often delayed unless a very
high index of suspicion is kept during initial assessment and
tertiary survey after resuscitation and stabilization of patients.
The mechanism of injury (acceleration and deceleration impact),
upper abdominal tenderness with tachycardia, raised temperature
and vomiting should warrant further evaluation. Contrast-
enhanced computed tomographic scan of the abdomen with
oral and intravenous contrast media is highly sensitive to detect
small amounts of retroperitoneal air, paraduodenal hematoma or
extravasated contrast from the duodenum. Occasionally, contrast-
enhanced computed tomographic scan may also be negative
when performed early or may suggest subtle findings like small
amount of unexplained fluid or unusual bowel morphology due
to paraduodenal hematoma.[5-7]
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Bhattacharjee, et al.: Duodenal injury following blunt abdominal trauma
There are several options to deal with duodenal injury, which range
from simple repair like primary closure (duodenorrhaphy) to more
complex procedures like resection and anastomosis, duodenal
diverticulation, pyloric exclusion, pancreaticoduodenectomy.
However, no single method of repair completely eliminates the
possibility of a duodenal fistula.[8] Most of the duodenal injuries
are adequately managed with primary closure (duodenorrhaphy)
in one or two layers or by resection and anastomosis.[2,6,8]
Options are limited for a patient presenting late with sepsis.
This was evident in both of our cases. In both the patients,
damage control surgery in the form of polypropylene mesh
laparostomy after duodenorrhaphy, tube gastrostomy, reverse
tube duodenostomy and a feeding jejunostomy was performed.
Salvage procedures like quick damage control with delayed
definitive surgery, Foley catheter duodenostomy, duodenal
decompression by quadruple tube technique are sparingly
reported.[6,9,10]
Both of our patients were effectively managed by simple repair
and duodenal decompression by triple tube technique. Simple
repair followed by duodenal decompression with triple tube
technique was originally described by Stone and Fabian.[11]
This triple tube technique comprises a tube gastrostomy for
decompressing the stomach, a reverse tube duodenostomy for
duodenal decompression and an antegrade tube jejunostomy
for enteral feeding [Figure1]. For reverse tube duodenostomy,
the tube is passed through the proximal jejunum and guided
into the second part of duodenum. This triple tube technique
is rapid, needs only basic surgical experience, and provides a
portal for early enteral feeding obviating the need for intravenous
hyperalimentation. Thus, it is a cost-effective option with least
morbidity for managing these severely injured sick patients.
In our first case, the injury on the posterior wall of the
duodenum was missed at the time of the first laparotomy. The
obvious perforation on the anterior wall probably prevented the
operating surgeon from proper mobilization (Kocherization) of
the duodenum. In the second patient, the index of suspicion
for severe internal injury was low in view of absence of clinical
signs, hence the patient was discharged.
Mobilization of the duodenum is known to reveal significant
injury even in the absence of apparent signs of trauma on it.[12]
Recently, Zeli etal.[13] reported a case of complete transection
of the duodenum at two places, one just beyond the pylorus and
the other between the second and third part of duodenum.[13]
This report, as well as our first case, highlights the possibility of
duodenal injury occurring at multiple sites. We strongly suggest
that in all major blunt trauma cases, even in the presence of
obvious perforation on the duodenum, the duodenum should
always be mobilized and evaluated for additional injury.
Another option to manage such patients could have been
a controlled duodenal fistula following peritoneal lavage.
However, we preferred triple tube decompression as the feeding
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jejunostomy associated with the procedure helps in early enteral
feeding, thereby avoiding the need for more expensive total
parenteral nutrition (TPN) with its attendant complications.
The mesh laparostomy prevents evisceration of gut and the
abdominal compartment syndrome. It also facilitates drainage
of infectious material, permits visual control of the underlying
viscera, facilitates wound care, simplifies repeated exploration if
required, and hastens healing by secondary intention.
Isolated duodenal injury following blunt abdominal trauma
is rare; therefore, most general surgeons have a low index of
suspicion and may not be experienced in handling such problems.
These two cases highlight the difficulties that can be encountered
during diagnosis and management of blunt abdominal trauma
with isolated duodenal injury. The diagnosis depends on a
high index of suspicion not only during the initial clinical
evaluation but also during trauma related laparotomies. When
diagnosed late, especially when the patients general condition is
severely compromised, simple duodenorrhaphy with duodenal
decompression by triple tube technique may be a good selection
because the procedure is simple, rapid, and provides a portal for
early enteral feeding.
ACKNOWLEDGMENTS
The authors thank Mr. Pirmin Storz, Section for Minimal Invasive
Surgery, University Hospital Tuebingen, Germany, for his technical help
in the preparation of the graphic illustration, and Prof. Shaji Thomas,
Department of Surgery, Lady Hardinge Medical College, New Delhi,
for his expert help in the editing the manuscript.
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How to cite this article: Bhattacharjee HK, Misra MC, Kumar S,
Bansal VK. Duodenal perforation following blunt abdominal trauma.
J Emerg Trauma Shock 2011;4:514-7.
Received: 05.08.10. Accepted: 23.03.11.
Source of Support: Nil. Conflict of Interest: None declared.
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