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Duodenal Injury

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What is Duodenal Injury

Most of the duodenum in the retroperitoneal injury incidence is very low, about 3.7% to 5% of the entire abdominal trauma; the injury is more common in the duodenum, three (3/4). Early cause of death after injury is a serious associated injuries, especially abdominal vascular injury; late death not timely diagnosis and treatment. Improper the duodenum fistula, caused by infection, bleeding and organ failure. Duodenal injury (duodenal injury) as part of the abdominal cavity, pancreatic juice and bile into the abdominal cavity, causing peritonitis early rupture.

Symptoms of Duodenal Injury

(A) of the duodenal wall hematoma

Relatively rare. Mostly occurs in children. Only upper abdominal discomfort or mild abdominal pain, longer duration after injury. Due to the hematoma compression can cause partial obstruction of duodenum. Dilatation of the stomach, the stomach wall hypertrophy, vomiting, deep tenderness in the upper abdomen, but no muscle tension. Right upper quadrant can often palpable mass, delayed perforation may also occur.

(B) duodenal rupture or fracture

Intraperitoneal duodenal rupture

Duodenal contents flow into the abdominal cavity, peritoneal signs obvious manifestations of severe abdominal pain, muscle tension, abdominal tenderness, rebound tenderness.

Retroperitoneal duodenal rupture

The duodenal contents logistics into the retroperitoneal space, the performance of the upper abdomen and lumbar back pain, upper abdominal tenderness, abdominal tenderness and rebound tenderness.

3. Duodenum, pancreas associated injuries

Retroperitoneal duodenal injury combined with pancreatic contusion. Is manifested mainly to the upper abdomen and lower back pain. Such as duodenal injury combined with pancreatic duct rupture or pancreatic fragmentation, pancreatic juice, intestinal fluid and blood out of the abdominal cavity, showed signs of peritonitis, peritoneal fluid pancreatic amylase increased.

What Causes Duodenal Injury

Etiology and pathology

The cause of duodenal injury:

(A) direct penetrating injury

Due the duodenum located in the abdominal cavity deep damage opportunities are few, if any damage, more associated with other organ damage. Also found that the injury is more common in the duodenum, three in the laparotomy mostly easy.

(B) non-penetrating injury

Most of the duodenum is protected better, only its transverse part of the front of the spine are more susceptible to injury, usually caused the abdomen by strong squeezing or rolling injury, duodenum pressure results in the injury of between external force and spine. The majority of the injured area at both ends of the duodenum and the duodenum, jejunum song, and about 25% in the transverse part of the duodenum, is often associated with damage to the liver, pancreas, spleen, small intestine and right kidney. Part of the duodenum in the retroperitoneal, non-penetrating duodenal injury is often difficult to be found, often resulting in fatal consequences, a mortality rate of up to 30%.

(C) iatrogenic injury

Any severe adhesions in the right upper quadrant surgery, such as biliary surgery, have the possibility of rupture of the duodenum. Multiple biliary tract surgery, adhesions more anatomical relationship is unclear, surgical separation of adhesions must be patient, clear anatomical relationship before bile duct. Occasionally, the lower end of the common bile duct stenosis and and the exploration expansion with spies, too blunt duodenal perforation.

Tests and Diagnosis for Duodenal Injury

Diagnosis

Patients with a history of trauma of the upper abdomen, chest and lower back.

(A) of the duodenal wall hematoma

x-ray barium meal examination, visible folds of the duodenal mucosa, rough, thickening, luminal stenosis, part of the barium through. B ultrasonic examination, the diagnosis.

(B) duodenal rupture or fracture

Intraperitoneal duodenal rupture

The x-ray examination showed subdiaphragmatic free gas, abdominal cavity within the liquid plane. Abdominal puncture bleeding liquid, increased the abdominal examinations pancreatic amylase.

Retroperitoneal duodenal rupture

If there is no merger injured. Abdominal puncture negative, or even see the retroperitoneal laparotomy a huge hematoma, the inexperienced surgeon uncut peritoneal also missed. The resulting postoperative retroperitoneal duodenal fistula, retroperitoneal serious infection, the mortality rate is extremely high. Blur visible the perirenal product gas, or shadow of the psoas muscle, and contribute to the diagnosis based on history, clinical manifestations, KUB check. Oral water-soluble contrast agent, can be seen leaking from the rupture.

3. Duodenum, pancreas associated injuries

Duodenal injury site in the retroperitoneal or intraperitoneal combined pancreas injury is a contusion or whether the pancreatic duct rupture.

Treatments of Duodenal Injury

Treatment

Duodenum has a poor blood supply, fixed position, cavity bile, pancreatic juice soak, high-pressure, intestinal wall bare area serosa protection characteristics, surgical treatment required after injury discretion.

(A) The basic principles of surgery

The basic principle of the surgery is: (1) early surgical exploration; ② good surgery revealed; ③ find bowel rupture; the ④ carefully patched with the effective duodenal decompression; combined other organ damage; ⑥ ⑤ prevent collapse leakage the celiac effective drainage.

(B) surgical exploration

Before surgery that should keep good intravenous access in case you need rapid blood transfusion should be the placement of a nasogastric tube suction to prevent gastric juice into the abdominal cavity by duodenal lacerations. The broad-spectrum antibiotics should be injected immediately open abdominal injury patient. Surgical exploration must be carefully. First surgery for abdominal incision, the need to extend further down. Into the abdomen should promptly viscera move in order to view the retroperitoneal, intra-abdominal blood clot and hemorrhage should quickly clear any non-fatal bleeding temporarily gauze pad tamponade, left behind so as not to plow the main source of the bleeding. Major vascular injury is often the main cause of death must be controlled. Found duodenum near the peritoneal hematoma organization bile stained yellow or crepitus the transverse mesocolon roots there, should doubt the possibility of rupture in the duodenum peritoneal. The retroperitoneal duodenum outside of this time should be cut or transverse mesocolon retroperitoneal film roots. Exploration of the duodenum transverse portion and the descending portion.

(3) Surgical treatment

In the treatment of duodenal injury generally follow the following principles:

Surgery, diagnosis and treatment of duodenal injury should be allowed in the other bleeding associated injuries, such as the liver, spleen, caused by bleeding.

The vast majority of duodenal injury can be simple debridement, but if accompanied by tissue defects blockbuster duodenal blood supply and demand excision or accompanied by more than 2/3 of the circumference of the bowel wall contusion no constant repair, to be based on the resourcefulness of the wound size, location, shape, and associated injuries, and the flexibility to consider. Such as cracks larger, can not direct suture, free short pedicled bowel to cut coverage rupture. Duodenum third, four seriously dampened should not suture the bowel segment resection anastomosis. If the tension is too large and can not be stitched, you can turn off the remote, the proximal intestine anastomosis or off the two ends, side-to-side anastomosis for duodenum and jejunum. Duodenum First, Sec serious injury can make the duodenum fistula and stomach cavity intestinal anastomosis, in order to achieve the purpose of the exclusion of the duodenum. Likewise, such as the duodenum, the second paragraph of serious fragmentation bring disaster to the head of the pancreas can not restorers feasible pancreaticoduodenal resection, surgical trauma, the mortality rate is high.

Regardless of the purposes of the foregoing which surgery is required for abdominal drainage.

Postoperative treatment and complications.

Should the indwelling nasogastric decompression to avoid irritation of the duodenum and pancreas secretion. The postoperative continue rehydration, intestinal paralysis and infection complications the patient, intravenous nutrition can be maintained until after 4 to 5 days.

5-7 days after the operation the patient, such as intestinal paralysis disappears, you can disconnect the tube, gradually try with a small amount of oral diet, if tolerated, can be gradually increased, until the return to normal diet. Peritoneal drainage will generally also be removed. However, if there is still secretions drainage for two weeks, or even longer.

Serious complications after duodenal injury surgery fistula, duodenal stenosis, followed by the retroperitoneal space infections, pancreatic fistula, abdominal cavity and subphrenic abscess. Duodenal injury surgical options to consider reducing the incidence of complications. Postoperative duodenal decompression and peritoneal drainage, as well as to strengthen nutrition is to reduce or avoid these complications occurred. Event pancreatic fistula should complete drainage of late from the drainage tube inject hypertonic glucose, and promote the healing of the fistula. Local small doses of radiation therapy can also accelerate pancreatic fistula healing.

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active 7 March 2013 at 16:11

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