Management of duodenal injuries

Abstract

Duodenal injuries is a very serious complication that carries a high mortality rate especially when diagnosed late, but it is also infrequently injured dueto its deepandrelativelyprotectedby many nearby organs. Duodenum may be injured due to traumatic or non-traumatic causes. Traumatic perforation may be due blunt injury: civil violence, road traffic accident, or penetrating injury: gunshot, knife, iatrogenic injury e.g. during ERCP, open or laparoscopic operations. Non-traumatic (pathological) injury may be due to perforated peptic ulcer, perforated diverticulum. There is significant difference between adults and children duodenal injuries e.g. blunt injuries and duodenal haematoma are more common in children, healing of duodenal injuries is better in children than adult, and thus simple repair can be done in children with more encouraging outcome than adults. Due to the retroperitoneal site of duodenum, the clinical diagnosis is difficult unless a high index of suspicion is maintained. Initial physical examination is usually generally negative and diagnostic delay is common. Midepigastricpain isthe most common symptom, followed by signs of chemical peritonitis within few hours. CT scan with both oral and intravenous contrast medium is of paramount importance.CT has improved the ability to examine and detect duodenal injuries. Patients with low grade duodenal injuries or injuries that are detected early, simple repair is adequate, patients with severe duodenal injuries may require more sophisticated repair if suture wound dehiscence is expected. There are new protocols for management of duodenal injuries post duodenal ulcer and ERCP, also laparoscopic repair of duodenal injury is a trend that can be done concerning many cases of duodenal injury under certain conditions. Conservative management of selected cases of duodenal injury can be chosen but many precautions must be thought of and close observation is highly important.