THROUGH-AND-THROUGH BLUNT DUODENAL INJURY IN A PEDIATRIC TRAUMA PATIENT: A CASE REPORT

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Background: Isolated duodenal injuries from blunt abdominal trauma are rare but classically present following a forceful impact to the epigastrium such as bicycle handlebar, motor vehicle accident, fall, child abuse, and trampoline bar. Multi-organ injury, including the pancreas and liver, is most commonly seen with these type of duodenal injuries. Due to its retroperitoneal location, recognition of isolated injury to the duodenum may be delayed.

Summary: We present an 11-year-old who arrived in the emergency department complaining of abdominal pain 2 hours after a high impact handlebar injury wherein her teenage sibling fell on top of her with handlebar against epigastrium. On arrival, she was tachycardic, without nausea or emesis, with a leukocytosis of 17,100/uL and tenderness in the right upper quadrant. Abdominal CT demonstrated duodenal injury with free intraperitoneal air. Laparotomy revealed an anterior duodenal injury. This was primarily repaired; however, upon testing repair for leakage, a large posterior injury was also identified. So rather than a single full-thickness explosive rent in the wall, we discovered dual full thickness lacerations secondary, presumably, to high pressure force/compression. The injuries were distal to the ampulla of Vater, involving ~50% of the bowel circumference combined. After performing a Kocker maneuver for further duodenal mobilization, both defects were repaired primarily with single-layer interrupted sutures and a drain was placed. Upper GI series 8 days later revealed mild narrowing without obstruction or leak. Nasogastric tube was removed on post-op day #11. On post-op day #13, drain was removed, and the patient was discharged tolerating a regular oral diet. At one month, patient was back in school without additional symptoms.


Conclusion: This case illustrates the successful management of a through-and-through isolated duodenal perforation in the setting of blunt abdominal trauma and demonstrates the importance of thorough evaluation as posterior injury could have easily been missed resulting in poor patient outcome.

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