Unusual presentation of Trans-section injury of the Duodenum due to blunt abdominal trauma

Moheb M Gaid and T Davies

Case History

Thirteen years old girl presented with blunt trauma after being kicked by her horse (hoof marks shown in Figure 1).

Figure 1 Imprint of the hoof marks two days later.

Initial assessment shows

• clear airways
• normal breathing
• haemo-dynamically stable
• normal GSC

On examination she was found to have a closed fracture of the humerus and painful right upper quadrant of abdomen. A few minutes later she vomited dark clotted blood. Whilst still haemo-dynamically stable, CT scan was performed and showed a collection of fluid in the retroperitoneal space with a suspected mesenteric haematoma and an incomplete circumference of the duodenum (Figure 2).

Figure 2 CT scan showing the incomplete circumference of the duodenum retroperitoneal haematoma.

The patient underwent laparotomy and complete trans-sectional rupture of the second part of the duodenum was found fortunately sparing the Ampulla of Vatar. Primary repair was performed followed by an uncomplicated early recovery with no complications when seen at six month follow up.

Comment

Complete trans-sectional injury of the duodenum is uncommon in blunt abdominal trauma (1) and remains a diagnostic challenge due to vague acute symptoms and limited radiological signs (2). In our case, the patient had a significant haematemesis which suggested upper gastrointestinal injury aiding the radiologist in identifying the duodenal injury. The diagnosis is usually made during emergency laparotomy or later when peritonitis develops.

References

1) Br J surgery. 1974 Nov; 61 (11): 893-895
2) South Medical J. 1984 Sep; 77 (9): 1078-1082