Delayed Presentation of Duodenal Perforation after a Blunt Abdominal - - PDF document

CASE REPORT

Delayed Presentation of Duodenal Perforation after a Blunt Abdominal Injury-A Case Report

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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)

Key words;

blunt abdominal contusion, duodenal injury, duodenal perforation INTRODUCTION CASE REPORT Duodenal injury is a rare condition, typically asso- ciated with a direct blow to the epigastrium due to a traffic accident or a sports injury [I]. Diagnostic delay is common 121. The incidence of traumatic duodenum injury is lower than most other abdominal organ injury, with reported rates of 3.5% to 12% [3]. In a previous report, the delay to operative intervention greater than 24 hours was associated with a s i ~ i c a n t l y higher mor- tality rate than those treated w i t h 24 hours of the inci- dent (5% vs 1670, p<0.18) [4]. The time to operation greater than 24 hours implies an increase in the mortal- ity rate from 1 1 % to 40% [I ]. However, blunt duodenal injuries remain a diagnostic and therapeutic challenge. This may'be because of the nonspecfic signs and symp- toms at first. A 20-year-old man was brought to the emergency department with a blunt abdominal injury caused by the handle bar of his motorcycle. Physical examination re- vealed a localized tenderness and abrasions over his upper abdomen (Fig. 1). There were several abrasions

• ver his lower chin and extremities. No extremity de-

formity was noted. His blood pressure, pulse rate, and body temperature were within normal limits. The bed- side ultrasonography found no ascites in the abdomen at that time. The chest X-ray film was normal. There was no free air below the diaphragm. The emergency department physician suggested that the stay in the emer- gency department for observation of possible changes but the patient insisted on leaving. 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

• f 4300/mm3,

with the differential count of neutrophils 24/min. He had no fever. There was tenderness over the

• f band form at 23%, segment form at 29%, lympho-

cytes at 19% and eosinophil at 1

%. The level of K was

• Fig. 1. Photograph of the abdomen revealed abrasion wound
• ver the upper abdomen.
• Fig. 2. The KUg revealed retroperitoneal gas collection in
• Fig. 3. Abdominal C

T

scans revealed right perirenal air col- lection (arrow). 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/ dL, CK was 271 IU/L, Creatinine was 1.5 mg/dL, GOT was 20 IU/L> glucose was 160 mg/dL, PT was 14.1 sec, INR was 1.31, and APTT was 1.3 1 sec. On the day after the second admission, amylase was 374 IU/L and lipase was 2026 IU/L. The abdominal sonography showed minimal ascites in the abdomen. Contrast-enhanced co111- puterized tomographic (CT) scans (Fig. 3j of the abdo- men showed large amounts of gas and fluids collected in the right perirenal and right anterior pararenal spaces with downward extension to the right pelvic region. The 2-D coronal reconstruction CT scan images (Fig. 4) re- vealed a perforation over the third portion of the

• duodenum. An emergency operation was arranged. The
• perative findings showed one 0.5 x 1.0 cm perforated

hole over the second to third portion of the dnodenunl with food debris spilling over the retroperitoneal space where an abscess forination that measured approximately. 300 mL was found. The stomach was distended with hematoma forination over the greater omentum. The operative procedure included duodenorrhaphy, choledochotomy with T-tube drainage, feeding jejunos- tomy tube insertion, retroperitoneal exploration, and drainage. Several days after the operation, upperG1,series was performed and showed that the perforation had healed. He recovered without complications and was discharged 22 days after the operation.

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DISCUSSION Duodenal injury is a rare condition. The duodenum lies in the retroperitoneum and it often combines with

• ther severe injuries such as fractures or other organ
• injuries. Pancreatic injuries are the most common in-

jury associated with duodenal trauma. The morbidity for patients with duodenal injuries is more dependent on associated injuries than on the degree of the duodenal injury [5]. A blunt duodenal injury is less common and more difficult to diagnose than a penetrating injury [2]. CT scanning with intravenous contrast remains a valuable tool in the diagnosis of blunt duodenal injuries [6]. Retroperitoneal extralurninal air seen on CT scan is an important sign for the duodenal perforation [7]. Usually, the oral contrast medium is not used in the emergzncy department due to the possibility of an emer- gency operation. The air can usually be seen without

• ral contrast medium enhancement. Despite the effec-

tiveness of the CT scan, there are still some false nega- tive findings during the initial evaluation. Thus we must maintain a high index of suggestion in the patients with possible injuries [8]. Delayed diagnosis is frequent due to the relatively low incidence. Clinical presentation maybe very subtle before peritonitis develops. Delays in diagnoses lead to poorer outcomes. We found the lo- cation of the duodenal perforation in our patient with the help of CT scan before the operation. The good prog- nostic factors for the patient may include the young age, lack of underlying disease, excellent surgical technique and state of the art treatment. The surgical repair is a safe and effective therapy for the duodenal perforation. The operative methods for duodenal injuries are complicated. The pre-pyoric ex- clusion method is indicated for most duodenal injuries except for minor local hematomas or severe pancreatic and duodenal rupture. The nutritional supplenlentation through the jejunostomy tube is beneficial [9]. Early detection, early diagnosis, and early treatment of duode- nal injuries has shown good prognoses.

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