CASE REPORT Delayed Presentation of Duodenal Perforation after a Blunt Abdominal Injury-A Case Report L b jL Z* ty Jui-Kun Chiang, Chih-Wen in', Chang-Kuo wei2, Sheng-Chuan H U ~ Department o f Family Medicine, ~ a d i o l o ~ ~ ' , General surgery2, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; Department o f Emergency ~edicine~, Buddhist Tzu Chi General Hospital, Hualien, Taiwan ABSTRACT The duodenum is an organ in the retroperitoneum and a single injury from a blunt abdominal injury is rare. Thus, delayed presenta- tion and missed diagnosis are often seen. We present a case with blunt abdominal contusion resulting from a motorcycle accident. The patient returned to the Emergency department 17 hours after being discharged due to the progressive peritoneal symptoms. The computerized tomographic (CT) scan is an ideal tool for the possible need of laparotomy by detecting the extra-bowel free ai~ and fluid. Laparotomy is nearly the only method to localize the position of perforation and to treat the disease. Early identification and treatment are the key points to decreasing the mortahty rate. With the help of the reconstructive function of the ( 3 scan, we detected the location of perforation before the operation. (TZU Chi Med J 2005; 17:191-193) blunt abdominal contusion, duodenal injury, duodenal perforation Key words; CASE REPORT INTRODUCTION Duodenal injury is a rare condition, typically asso- A 20-year-old man was brought to the emergency ciated with a direct blow to the epigastrium due to a department with a blunt abdominal injury caused by the traffic accident or a sports injury [I]. Diagnostic delay handle bar of his motorcycle. Physical examination re- is common 121. The incidence of traumatic duodenum vealed a localized tenderness and abrasions over his injury is lower than most other abdominal organ injury, upper abdomen (Fig. 1). There were several abrasions with reported rates of 3.5% to 12% [3]. In a previous over his lower chin and extremities. No extremity de- report, the delay to operative intervention greater than formity was noted. His blood pressure, pulse rate, and 24 hours was associated with a s i ~ i c a n t l y higher mor- body temperature were within normal limits. The bed- tality rate than those treated w i t h 24 hours of the inci- side ultrasonography found no ascites in the abdomen dent (5% vs 1670, p<0.18) [4]. The time to operation at that time. The chest X-ray film was normal. There greater than 24 hours implies an increase in the mortal- was no free air below the diaphragm. The emergency % to 40% [I ]. However, blunt duodenal ity rate from 1 1 department physician suggested that the stay in the emer- injuries remain a diagnostic and therapeutic challenge. gency department for observation of possible changes This may'be because of the nonspecfic signs and symp- but the patient insisted on leaving. toms at first. The next day, about 17 hours after his initial admis- Received: May 14,2004, Revised: June 1,2004, Accepted: July 7,2004 Address reprint requests and correspondence to: Dr Jui-Kun Chlang, Department of Family Medicine, Buddhist Dalin Tzu Chi General Hospital, 2, Ming Sheng Road, Dalin, Chiayi, Taiwan Tzu Chi Med J2005 . 17 . No. 3
J. K. Chiang, C. W. Lin. C. K. Wei, era/ sion to the emergency department, the patient came to whole abdomen and decreased bowel sounds was noted. the emergency department again. He had abdomen pain, We arranged to perform a KUB film for him (Fig. 2). vomiting, and dysuria. His blood pressure was 102161 The laboratory test results showed white blood cell count d g , heart rate was 102jmin and respiratory rate was of 4300/mm3, with the differential count of neutrophils He had no fever. There was tenderness over the of band form at 23%, segment form at 29%, lympho- 24/min. cytes at 19% and eosinophil at 1 %. The level of K was Fig. 1. Photograph of the abdomen revealed abrasion wound over the upper abdomen. Fig. 3. Abdominal C T scans revealed right perirenal air col- lection (arrow). Fig. 2. The KUg revealed retroperitoneal gas collection in the right prirenal space (arrow) with downward ex- Fig. 4. Coronal reconstructed CT scans revealed duodenal tension into the upper pelvic cavity (arrow head). defect over the 3rd portion of the duodenum (arrow) and retroperitoneal gas collection. Tsu Chi Med J 2005 . 17 - No. 3
3.66 mmol/L, Na was 133 mmol/L, BUN was 18 mg/ maintain a high index of suggestion in the patients with dL, CK was 271 IU/L, Creatinine was 1.5 mg/dL, GOT possible injuries [8]. Delayed diagnosis is frequent due was 20 IU/L> glucose was 160 mg/dL, PT was 14.1 sec, to the relatively low incidence. Clinical presentation INR was 1.31, and APTT was 1.3 1 sec. On the day after maybe very subtle before peritonitis develops. Delays in diagnoses lead to poorer outcomes. We found the lo- the second admission, amylase was 374 IU/L and lipase was 2026 IU/L. The abdominal sonography showed cation of the duodenal perforation in our patient with minimal ascites in the abdomen. Contrast-enhanced co111- the help of CT scan before the operation. The good prog- puterized tomographic (CT) scans (Fig. 3j of the abdo- nostic factors for the patient may include the young age, men showed large amounts of gas and fluids collected lack of underlying disease, excellent surgical technique and state of the art treatment. in the right perirenal and right anterior pararenal spaces with downward extension to the right pelvic region. The The surgical repair is a safe and effective therapy 2-D coronal reconstruction CT scan images (Fig. 4) re- for the duodenal perforation. The operative methods for vealed a perforation over the third portion of the duodenal injuries are complicated. The pre-pyoric ex- duodenum. An emergency operation was arranged. The clusion method is indicated for most duodenal injuries operative findings showed one 0.5 x 1.0 cm perforated except for minor local hematomas or severe pancreatic and duodenal rupture. The nutritional supplenlentation hole over the second to third portion of the dnodenunl with food debris spilling over the retroperitoneal space through the jejunostomy tube is beneficial [9]. Early where an abscess forination that measured approximately. detection, early diagnosis, and early treatment of duode- 300 mL was found. The stomach was distended with nal injuries has shown good prognoses. hematoma forination over the greater omentum. The operative procedure included duodenorrhaphy, REFERENCES choledochotomy with T-tube drainage, feeding jejunos- tomy tube insertion, retroperitoneal exploration, and drainage. 1. Ahn MS, Miya~ K, Carethers JM: Intramural duodenal hematoma presenting as a complication o f peptic ulcer Several days after the operation, upperG1,series was disease. J Clin Gastroenterol2001; 33:53-55. performed and showed that the perforation had healed. 2. Aherne NJ, Kavanagh EG, Condon ET, Coffey JC, E l He recovered without complications and was discharged Sayed A, Redmond HP: Duodenal perforation after a 22 days after the operation. blunt abdominal sporting injury: The Importance o f Early Diagnosis. J Trauma 2003; 54:791-794. 3. Soeta N, TerashimaS, Kogure M, Hoshino Y, Gotoh M : DISCUSSION I Successful healing o f a blunt duodenal rupture by - .- . --. . nonoperative management. J Trauma 2002; 52:979- 981. Duodenal injury is a rare condition. The duodenum 4. Watts DD, Fakhry SM: EAST Multi-Institutional Hollow lies in the retroperitoneum and it often combines with Viscus Injury Research Group: Incidence o f hollow vis- other severe injuries such as fractures or other organ cus injury in blunt trauma: An analysis from 275,557 injuries. Pancreatic injuries are the most common in- trauma admissions from the East multi-institutional trial. jury associated with duodenal trauma. The morbidity for J Trauma 2003; 54289-294. 5. Kushimoto S, Mun M, Yamamoto Y, Harada N, Sato N , patients with duodenal injuries is more dependent on Koido Y: Duodenal mucosal injury caused by blunt ab- associated injuries than on the degree of the duodenal dominal trauma. J Trauma 2001 ; 51:591-593. injury [5]. A blunt duodenal injury is less common and 6. Killen KL, Shanmuganathan K, Poletti PA, Cooper C, more difficult to diagnose than a penetrating injury [2]. Mi~is S: Helical computed tomography o f bowel and CT scanning with intravenous contrast remains a mesenteric injuries. J Trauma 2001 ; 51 :26-36. valuable tool in the diagnosis of blunt duodenal injuries 7. Timaran CH, Daley BJ, Enderson BL: Role o f [6]. Retroperitoneal extralurninal air seen on CT scan is duodenography in the diagnosis o f blunt duodenal injuries. J Trauma 2001 ; 51 :648-651. . an important sign for the duodenal perforation [7]. 8. Desai KM, Dorward IG, Minkes RK, Dillon PA: Blunt Usually, the oral contrast medium is not used in the duodenal injuries in children. J Trauma 2003; 54:640- emergzncy department due to the possibility of an emer- 646. gency operation. The air can usually be seen without 9. Fang JF, Chen RJ, Chen MF, et al: Surgical treatment oral contrast medium enhancement. Despite the effec- and outcome o f blunt duodenal trauma after delayed tiveness of the CT scan, there are still some false nega- diagnosis. J Surg Assoc ROC 1993; 26:1545-1550. tive findings during the initial evaluation. Thus we must
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