Version May 2024
INTRODUCTION — Injuries of the duodenum are relatively infrequent, and the diagnosis and management can be challenging. The signs and symptoms of duodenal injury are nonspecific, and duodenal injuries are frequently associated with concomitant injuries. Management of duodenal injuries depends on the mechanism of injury (blunt or penetrating) and injury grade. Concomitant injuries may require more urgent attention, necessitating a damage control approach for the duodenal injury.
The mechanisms, associated injuries, diagnosis, and management of duodenal injury in adults are reviewed. Pancreatic injury often accompanies duodenal injury and is reviewed separately. (See "Management of pancreatic trauma in adults".)
The general approach to blunt and penetrating abdominal trauma is reviewed separately. (See "Initial management of trauma in adults" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)
DUODENAL ANATOMY — The duodenum is primarily a retroperitoneal organ that begins at the pylorus and ends at the ligament of Treitz (figure 1).
The duodenum measures approximately 20 cm and consists of four segments:
●The first portion of the duodenum is transversely oriented, beginning at the pylorus and ending at the common bile duct superiorly and the gastroduodenal artery inferiorly.
●The second portion of the duodenum runs inferiorly to the ampulla of Vater.
●The third portion of the duodenum runs transversely to the superior mesenteric artery and vein.
●The fourth portion of the duodenum extends to the point where the duodenum emerges from the retroperitoneum to join the jejunum at the left border of the second lumbar vertebra.
The second portion of the duodenum is the most common site for duodenal injury [1,2]. In the comprehensive review, among 15 studies reporting a total of 1042 patients with duodenal injury, the site of duodenal injury was second portion (36 percent), third portion (18 percent), fourth portion (15 percent), multiple portions (18 percent), and first portion (13 percent) [2].
The duodenum is bordered anteriorly by the liver, colon, and stomach. The duodenal sweep is bordered by the gallbladder laterally and the head of the pancreas medially. Posteriorly, significant portions of the duodenum overlie the spinal column.
The pancreatic duct joins the common bile duct to drain into the duodenum via the major papilla (ampulla of Vater) (figure 2 and picture 1). The anatomy of these ducts can vary. In 85 percent of individuals, the pancreatic duct and the common bile duct enter the duodenum through a common channel. In 5 percent of patients, both ducts enter the duodenum through the same ampulla but via separate channels. In the remaining 10 percent of patients, each duct enters the duodenum through a separate ampulla [3]. The entry of the common bile duct into the pancreatic tissue posteriorly can also vary (figure 3).
The arterial supply to the duodenum (figure 4) is derived from the celiac artery providing the superior pancreaticoduodenal arteries (anterior and posterior branches) and the superior mesenteric artery providing the inferior pancreaticoduodenal arteries (anterior and posterior branches). The right gastric artery also gives branches to the duodenum. The venous drainage (figure 5) follows the arteries to provide tributaries to the superior mesenteric vein, which drain into the portal vein.
The duodenum is innervated by sympathetic fibers from the splanchnic nerves (figure 6) and parasympathetic fibers from the vagus.
TRAUMA EVALUATION — The initial resuscitation, diagnostic evaluation, and management of the patient with blunt or penetrating injury are based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma.
In the setting of acute trauma, many patients cannot relate their symptoms or medical history due to altered mental status (eg, neurologic injury, intoxication) or because they are intubated and sedated. Every attempt should be made to identify preexisting medical conditions. The presence of significant medical comorbidities and medical conditions requiring antiplatelet therapy or anticoagulation should be determined. (See "Overview of inpatient management of the adult trauma patient", section on 'Patient assessment'.)
Although Focused Assessment with Sonography in Trauma (FAST) is a useful, validated test for detecting hemoperitoneum in the setting of blunt trauma, it is not reliable as a screening test for duodenal injury. Approximately one-third of patients with retroperitoneal injuries, including injuries of the duodenum, will have normal FAST examinations [4,5]. Although diagnostic peritoneal lavage (DPL) does not sample the retroperitoneal space, most patients with duodenal injuries have associated injuries that may be detected by DPL; however, the test is not sufficiently specific for detecting duodenal injury [6]. As a result, stable patients with concern for duodenal injury require computed tomography (CT) imaging. Patients who are hemodynamically unstable due to ongoing hemorrhage will have their duodenal injury diagnosed at the time of operation. (See "Emergency ultrasound in adults with abdominal and thoracic trauma" and "Diagnostic peritoneal lavage (DPL) or aspiration (DPA)".)
Risk for injury — Duodenal injuries are uncommon, occurring in 1 to 5 percent of patients sustaining abdominal injuries [2,7-9]. Duodenal injury may be suspected based upon the injury mechanism or the identification of injury to organs in proximity to the duodenum. (See 'Duodenal anatomy' above.)
Injury mechanism — Overall, penetrating injury to the duodenum appears to be more common compared with blunt injury. In a comprehensive review that included 1760 duodenal injuries, 80 percent were the due to penetrating trauma [2]. Any implement or missile that enters the abdomen can injure the duodenum. Gunshot or shotgun wounds generally result in more severe injury compared with stab wounds because of their high energy. However, depending upon the girth of the victim and force applied, even a short implement that penetrates the upper abdomen can cause severe duodenal injury. In the comprehensive review, 81 percent of duodenal injuries were caused by gunshots, and 19 percent were from stabbings.
Blunt duodenal injury more commonly presents to trauma centers in the United States compared with penetrating injury [10]. This may be due in part to the higher incidence of blunt trauma in the US and the high lethality of penetrating injuries to this region of the body. Approximately 75 to 85 percent of blunt injuries to the duodenum are caused by motor vehicle crashes [2,8,11]. The mechanism is typically due to crushing the duodenum between the steering wheel or a seatbelt and vertebral column. Blunt duodenal injury can also be due to any other focal impact to the abdomen (eg, punch to abdomen, bicycle/motorcycle handlebar injury [2]). Deceleration (eg, high-speed impact, fall from a height) can also produce forces that act in which mobile and nonmobile portions of the duodenum meet, resulting in duodenal injury.
Associated injuries — The duodenum is rarely injured in isolation. Injuries associated with duodenal trauma from retrospective reviews include the following [1,2,8,12-14]:
●In a review of 1153 duodenal injuries, among 3047 associated injuries, the liver was the most injured organ, accounting for 17 percent of associated injuries [8]. Other organs injured along with the duodenum included the pancreas (12 percent), small bowel (12 percent), colon (12 percent), and stomach (9 percent).
●In another comprehensive review of 1760 patients, 3540 associated injuries were identified [2]. The liver was also the most injured organ, occurring in 17 percent. Other associated injuries included the colon (13 percent), pancreas (12 percent), small intestine (11 percent), stomach (9 percent), and vascular (arterial and venous) injuries (15 percent).
Because of their proximity to the duodenum, injury to major vascular structures including the aorta, vena cava, and portal vein can occur and lead to exsanguinating hemorrhage [8,13]. In the comprehensive review above, major abdominal veins were injured in 10 percent of patients, mostly involving the inferior vena cava, and major arteries were injured in 7 percent of patients, mostly involving the aorta [8]. (See "Abdominal vascular injury".)
CLINICAL EVALUATION
History and physical examination — Important historical information includes the mechanism of injury and information on the types and directions of the forces and points of impact (eg, condition of the steering wheel in motor vehicle crashes, height of fall, missile trajectory). A history of any blunt injury mechanism causing a blow or crushing injury to the mid- to upper abdomen raises the suspicion for duodenal injury. Symptoms associated with duodenal injury are nonspecific. In a small case series, epigastric pain and vomiting occurred in all patients, whereas fewer than half of patients exhibited back pain (36 percent), abdominal distention (36 percent), or peritonitis (43 percent) [1]. Extensive intramural hemorrhage in the duodenum can present as gastric outlet obstruction, which is often a delayed finding. (See 'Injury mechanism' above and "Management of pancreatic trauma in adults", section on 'Injury mechanism'.)
Abdominal tenderness and peritoneal signs on initial evaluation may indicate the presence of intra-abdominal injury but are not specific for duodenal injury. Spilling of duodenal contents into peritoneal space through foramen of Winslow in the setting of duodenal rupture can lead to widespread peritonitis, although it may take time to manifest. Spillage of contents into the lesser sac may even take longer to become apparent. A physical exam finding of abdominal wall ecchymosis may be a sign that a crush injury has occurred. In a study of 117 blunt abdominal injuries due to motor vehicle crashes, significantly more patients who presented with abdominal wall ecchymosis or the "seatbelt sign" had an intestinal injury (21 versus 2 percent) or intra-abdominal injuries requiring surgery (36 versus 4 percent) compared with those who did not have ecchymosis [15].
The thoracic and lumbar spine should be carefully palpated for spinal tenderness, which may indicate the presence of a spine fracture (image 1). Approximately one-third of patients with transverse vertebral body fractures (ie, Chance fracture) of the low thoracic or lumbar spine have intra-abdominal injuries [16].
Clinical symptoms and signs that may suggest an undiagnosed duodenal injury in patients who are being conservatively managed are reviewed below. (See 'Role of conservative management' below.)
Laboratory studies — Laboratory studies such as serum amylase or lipase are typically performed as a part of routine trauma assessment. An elevated serum amylase or lipase may be associated with duodenal injury, but these laboratory studies are not specific enough to establish or exclude the diagnosis. Furthermore, an elevated amylase or lipase can be present in patients with blunt abdominal trauma who do not have duodenal injury [17,18]. Alterations in serum amylase can also be due to a variety of conditions not associated with trauma, many of which do not involve the duodenum (table 1), and many drugs affect serum amylase values as well (table 2). (See "Approach to the patient with elevated serum amylase or lipase".)
DIAGNOSIS — Because symptoms and physical examination are nonspecific, the diagnosis of duodenal injury in hemodynamically stable patients is made by imaging studies, typically computed tomography (CT) of the abdomen. For those with immediate indications for laparotomy, duodenal injury may be identified during abdominal exploration.
Other specific imaging may be necessary to identify associated bile duct or pancreatic duct injury. However, it is important to note that in suspected duodenal perforations, endoscopic retrograde cholangiopancreatography is not recommended [7]. (See "Traumatic injury to the portal triad", section on 'Diagnosis' and "Management of pancreatic trauma in adults", section on 'Pancreatic imaging'.)
Duodenal imaging — The imaging diagnosis of blunt duodenal injury in hemodynamically stable patients relies primarily on CT of the abdomen. Abdominal CT for blunt abdominal trauma typically includes only intravenous contrast. Oral contrast administration is not usually necessary and generally does not improve the diagnosis of duodenal injury compared with intravenous contrast alone [7].
In some cases, initial abdominal films may demonstrate pneumoperitoneum that clearly indicates the presence of intestinal perforation, or the presence of air surrounding the right kidney, which is a more characteristic sign of duodenal injury, but this sign may be more common with penetrating trauma [8]. (See "Overview of gastrointestinal tract perforation", section on 'Imaging signs of perforation'.)
Duodenal CT findings can be regarded as direct or indirect [19-23]. Direct findings are more specific while indirect findings are more sensitive.
Direct CT findings include:
●Perforation
•Lack of continuity of the duodenal wall
•Diminished enhancement of the duodenal wall
•Extraluminal air or oral contrast adjacent to the duodenum
•Intramural air (incomplete perforation)
●Contusion
•Duodenal wall thickening of more than 4 mm
•Intramural hematoma
Indirect CT findings include:
●Periduodenal fluid or stranding
●Fluid or hemorrhage in the right anterior pararenal space
●Injuries to adjacent organs
Despite advances in CT technology, missed blunt injury to the duodenum continues to be a problem [2,24,25]. In retrospective reviews, the sensitivity of CT for detecting blunt small bowel injury has been reported to be as low as 59 or as high as 92 percent, with most studies not specifically evaluating duodenal injury [22,23,26,27].
Pitfalls of CT — Duodenal diverticula can be mistaken for extraluminal air. Similarly, underdistention of duodenum can appear like wall thickening or intramural hemorrhage.
If initial imaging does not show a duodenal injury but the ongoing clinical situation suggests that duodenal injury may be present, repeat CT scan with a request for oral contrast should be obtained and is preferable to alternative studies (eg, upper gastrointestinal series) [28]. The development of complications related to diagnosed or undiagnosed duodenal injury may also require further imaging. (See 'Complications of duodenal injuries' below.)
Diagnosis at laparotomy — For trauma patients with indications for emergency laparotomy, injuries to the duodenum should be actively sought during abdominal exploration. Techniques for exposing the duodenum and their intraoperative evaluation are discussed below; the evaluation of other retroperitoneal organs is reviewed separately. (See 'Abdominal exploration' below and "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Damage control laparotomy'.)
DUODENAL INJURY GRADING — The commonly used duodenal injury classification system is from the American Association for the Surgery of Trauma (AAST) (table 3) [29]. Although injury management does not correlate exactly with grade, this injury scale provides a practical means by which to communicate the severity of injury [29]. The initial severity of injury can be estimated based upon findings of computed tomography or more definitively during operative exploration.
●Grade I – Hematoma involving a single portion of duodenum or partial-thickness laceration without perforation.
●Grade II – Hematoma involving more than one portion or disruption <50 percent circumference or major laceration without duct injury or tissue loss.
●Grade III – Laceration with disruption of 50 to 75 percent circumference of second portion or disruption of 50 to 100 percent circumference of first, third, fourth portion.
●Grade IV – Laceration with disruption >75 percent circumference of second portion or involving ampulla or distal common bile duct.
●Grade V – Massive laceration with disruption of duodenopancreatic complex or devascularization of duodenum.
MANAGEMENT
Role of conservative management — Conservative management (ie, no intervention or duodenal repair) of duodenal injury is safe and can be suggested for hemodynamically stable patients with blunt grade I or grade II duodenal hematoma definitively identified on abdominal CT who otherwise have no indications for abdominal exploration [30-34]. Most often, however, the grade of duodenal injury is determined at the time of exploratory laparotomy for associated injuries. A duodenal hematoma identified during abdominal exploration may also be amenable to conservative management. Conservative management is not advised for penetrating mechanisms.
Conservative management consists of gastrointestinal decompression and nutrition support, as indicated. For patients with symptoms of proximal bowel obstruction due to duodenal hematoma, a nasogastric tube is placed for decompression and nutrition support is initiated. After five to seven days, imaging should be repeated to evaluate patency of the duodenum. If the obstruction has resolved, an oral diet can be initiated. However, if the obstruction persists after 10 to 14 days, exploratory laparotomy is indicated [35]. (See 'Low grade' below.)
During conservative management, careful follow-up is essential to monitor for symptoms or complications that indicate the need for surgical exploration. A retrospective multicenter study evaluated the outcomes of 230 patients with blunt pancreaticoduodenal injury [24]. Of the 97 patients managed nonoperatively, 10 patients (3 duodenal, 6 pancreatic) failed nonoperative management and required surgery.
When patients are being observed following trauma, the following clinical symptoms and signs may suggest an undiagnosed duodenal injury [36,37]:
●Increasing abdominal pain
●Increasing abdominal tenderness
●Persistent emesis or inability to tolerate oral diet
●Unexplained hypotension
●Increasing leukocytosis
●Increasing serum amylase or lipase
Nutrition support — Early enteral nutrition is preferred over parenteral nutrition for most injured patients [32,38-44]. However, placing and maintaining enteral access in patients with blunt duodenal injury can be challenging. (See "Overview of perioperative nutrition support", section on 'Indications' and "Inpatient placement and management of nasogastric and nasoenteric tubes in adults".)
Patients undergoing exploratory laparotomy and operative management of duodenal injuries can have a nasal-jejunal tube placed for decompression and/or feeding, or surgical jejunostomy placed prior to abdominal closure [42]. There are insufficient data to recommend routine feeding jejunostomy in all cases of operative duodenal injury given that approximately 4 percent of trauma patients will have complications related to surgical jejunostomy (eg, soft tissue infection, leak, enteric fistula, bowel obstruction) [45,46].
Abdominal exploration — Evaluation of the duodenum is mandatory for injured patients who undergo exploratory laparotomy for other indications. A significant number of patients with other abdominal injuries will be diagnosed with duodenal injury at the time of abdominal exploration. (See "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Damage control laparotomy'.)
Following control of abdominal hemorrhage or gastrointestinal contamination, the visible areas of the retroperitoneum should be inspected for bile staining, free biliary fluid, entrapped air bubbles, and periduodenal or perirenal hematomas. Retroperitoneal hematomas in the setting of penetrating trauma should be explored. (See "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Exploration of retroperitoneal hematoma'.)
If there is a high suspicion of duodenal injury due to a missile or highly associated injuries, each of the steps described below should be performed to mobilize and examine the duodenum.
●Perform a Kocher maneuver (figure 7) by dissecting the lateral peritoneal attachments of the duodenum to expose the first, second, and third portion of the duodenum.
●Divide the gastrocolic ligament to allow entry into the lesser sac and inspection of the posterior aspect of the first portion of the duodenum and the medial aspect of the second portion of the duodenum.
●Expose the third portion of the duodenum with a right medial visceral rotation.
●Mobilize the ligament of Treitz to expose the fourth portion of the duodenum.
The duodenum should be examined thoroughly for any full-thickness injury. When a duodenal hematoma is seen or palpated during emergency laparotomy for blunt trauma, it should be left intact since most of these will heal with conservative management. Although it may be tempting to evacuate the hematoma, doing so can potentially convert a partial-thickness injury into a full-thickness injury. Hematomas in the setting of penetrating trauma should be explored.
Most duodenal perforations are seen upon inspection. Subtle full-thickness injuries can be identified by instilling methylene blue through the nasogastric tube and looking for duodenal subserosal staining [47]. Full-thickness duodenal injury in the region of the ampulla indicates a need to fully evaluate the ampulla, bile ducts, and pancreatic ducts using cholangiopancreatography. (See "Management of pancreatic trauma in adults", section on 'Pancreatic imaging'.)
Damage control — Damage control surgery involves immediate control of bleeding sites (including those associated with duodenal or pancreatic injury) and gastrointestinal contamination with delayed management of injuries that are not immediately life-threatening, including duodenal injury. Intraperitoneal packing and temporary abdominal closure are followed by fluid resuscitation, patient warming, and correction of coagulation deficits in the intensive care unit [48]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Management of the open abdomen in adults".)
Damage control to manage duodenal injuries may involve rapid closure of the injured segment or resection of a full-thickness duodenal injury without reestablishing continuity [49].
Bleeding from high-grade pancreaticoduodenal injuries often cannot be controlled by packing, and thus resection with or without immediate reconstruction may be needed. The pylorus, pancreatic neck, and proximal jejunum are stapled across and resected, then anatomic vascular control is obtained, and the common bile duct is ligated. The biliary tract can be drained using tube cholecystostomy, or left to dilate to help with delayed reconstruction [50]. Closed-suction drains are placed to control duodenal and pancreatic secretions. Following resuscitation and stabilization, definitive resection and reconstruction (Whipple) can be performed. (See 'High grade' below.)
Repair of duodenal injury — The majority of duodenal lacerations can be managed by simple procedures such as debridement and primary repair, or resection and reanastomosis [31,51,52]. The need for more complex procedures is rare but is associated with an increased risk for postoperative complications, including suture line failure and anastomotic leak or small bowel fistula formation. Mortality is also increased with more complex repair but is often related to associated injuries and not strictly a consequence of duodenal repair. (See 'Morbidity and mortality' below.)
Approach by injury grade
Low grade — For patients who have failed conservative management of grade I or grade II duodenal hematoma (see 'Role of conservative management' above), the hematoma should be decompressed by exploratory laparotomy or laparoscopy by incising the serosa overlying the hematoma and evacuating as much blood clot as possible. Great care must be taken to assure the submucosa and mucosa are intact and there is no full-thickness defect [35].
Partial-thickness grade I duodenal lacerations identified at laparotomy are best repaired by suturing the serosa in a Lembert fashion. Full-thickness grade II duodenal lacerations are debrided, and the duodenum is repaired with a tension-free primary closure in one or two layers. Longitudinal injuries should be closed transversely, if possible, to minimize the potential for luminal narrowing. If the injury is judged to be too extensive (eg, >3 cm) for primary repair after debridement, the injured segment should be resected and the duodenal ends brought together with a primary end-to-end duodenoduodenostomy. Duodenal resection and primary anastomosis can be technically challenging and may not be possible depending on ability to mobilize adequately. Injuries to the second portion of the duodenum may not be amenable to this approach if the common bile duct or ampulla is injured, or if resection would require removal of these structures. The treatment of ampullary injuries is discussed below. (See 'High grade' below.)
Intermediate grade — As with low-grade duodenal lacerations, many intermediate grade III lacerations can also be treated with debridement and primary closure. When primary repair is not possible, resection with reanastomosis by duodenoduodenostomy is one option. For larger defects, a duodenojejunostomy with Roux-en-Y reconstruction should be considered. Although some advocate for additional procedures to protect the repair, such as pyloric exclusion, supporting data are limited. (See 'Adjunctive surgical techniques' below.)
High grade — High-grade (grade IV, V) duodenal lacerations involving the ampulla increase the complexity of duodenal repair.
For limited injuries to the ampulla, management options include stenting or sphincteroplasty [53].
Avulsion of the ampulla can occur and has been successfully managed with common bile duct reimplantation using choledochoduodenostomy [54,55].
Extensive periampullary injuries (eg, intraduodenal/intrapancreatic bile duct injury, massive combined pancreaticoduodenal disruption) often require staged pancreaticoduodenectomy [56].
Combined pancreatoduodenal injuries are associated with a high risk for morbidity and mortality [57]. In some patients with combined pancreatoduodenal injuries, the duodenal injury and pancreatic injury can be approached separately using relatively simple procedures. (See 'Repair of duodenal injury' above and "Management of pancreatic trauma in adults", section on 'Operative management of pancreatic injury'.)
When combined pancreatoduodenal injuries are more extensive, the risk of postoperative pancreatic and/or duodenal fistula is high. Tube decompression or other adjunctive surgical procedures can be considered to decrease the volume of secretions. Of the surgical techniques described below, pyloric exclusion is the most expedient and least complex option. (See 'Adjunctive surgical techniques' below.)
For patients with severe, combined pancreatoduodenal injury, such as when the ampulla of Vater or intrapancreatic common bile duct has been destroyed or the head of the pancreas has been devitalized, reconstruction is impossible and resection is needed. Fortunately, this rarely occurs. A damage control approach is often needed due to other associated injuries, which necessitates a staged procedure [50,58,59]. The head of the pancreas and proximal duodenum can usually be quickly resected (ie, pancreaticoduodenectomy) and drainage established. (See 'Damage control' above.)
Once stabilized, the patient is taken back to the operating room for reconstruction (figure 8 and figure 9). (See "Surgical resection of lesions of the head of the pancreas", section on 'Gastrointestinal reconstruction'.)
Adjunctive surgical techniques — Several adjunctive procedures have been used in conjunction with duodenal repair with a primary aim of decreasing the likelihood of leak following repair. For most duodenal injuries, adjunctive techniques are not needed. There is no consensus on when these procedures are indicated, and none of these techniques has demonstrated a clear benefit. Pyloric exclusion, duodenal decompression, and duodenal diverticularization are described briefly below.
●Pyloric exclusion – Pyloric exclusion refers to a procedure in which the pylorus is closed for the purpose of excluding gastric secretions from the duodenal repair. Pyloric exclusion may be selectively used as an adjunctive procedure to manage intermediate- or high-grade duodenal or combined injuries. The use of pyloric exclusion as an adjunct to the primary repair of duodenal injuries remains controversial and has been questioned by a number of studies. There has been no prospective trials comparing the use of this adjunct, so its selective use is largely based on surgical judgement at the time of explorations, and the severity of the duodenal injury [60-62]. (See 'Intermediate grade' above and 'High grade' above.)
Following duodenal repair, the pylorus is sutured closed through a longitudinal antral gastrotomy using partial-thickness absorbable or nonabsorbable sutures placed proximally into the pylorus or, alternatively, using a noncutting linear stapler applied transversely just distal to the pylorus. Once the pylorus has been closed, a loop gastrojejunostomy is performed.
The pylorus will reopen spontaneously in the majority of patients within three to six weeks, even when nonabsorbable sutures or staples are used. In a small retrospective review of 29 patients with penetrating duodenal injuries, no significant differences in clinical outcomes were seen for patients who underwent pyloric exclusion compared with those who underwent primary repair alone [63]. Although pyloric exclusion is a relatively straightforward procedure to perform, it is associated with a high incidence of marginal ulceration along the gastrojejunostomy.
●Duodenal decompression – Following repair, the duodenum can be decompressed in an antegrade (duodenostomy) or a retrograde (jejunostomy) fashion. In studies that have evaluated tube enterostomy, a serosal patch or mucosal graft taken from the jejunum or stomach has often been used to reinforce the duodenal repair. The rationale for duodenal decompression is to decrease the pressure and volume of secretions in the duodenum, thereby protecting the duodenal repair.
There are no randomized trials evaluating duodenal decompression in patients following duodenal injury, and the outcomes of retrospective reviews have been inconsistent [12,32,38,64-67]. Given the mixed results and the risk of other complications such as duodenal fistula, we prefer not to use duodenal decompression following duodenal repair.
●Duodenal diverticulization – Duodenal diverticulization refers to suture closure of the duodenal injury, antrectomy with end-to-side gastrojejunostomy, and tube duodenostomy [68]. Duodenal diverticularization is a complex, time-consuming procedure that is generally unnecessary.
POSTOPERATIVE CARE AND FOLLOW-UP — The necessary postoperative care and follow-up depends on the extent of surgery and the presence of any postoperative complications. Patients with multiple injuries may have initial damage control surgery and thus will require second-look laparotomy and open abdominal management, which is reviewed separately. (See "Management of the open abdomen in adults".)
Drains placed around the duodenum are monitored for rate of output for subsequent removal.
Postpyloric enteral feeding is preferred for nutrition support, and so placement of a nasal jejunal feeding tube or feeding jejunostomy should be considered at the time of surgery for patients with severe injury. (See 'Nutrition support' above.)
MORBIDITY AND MORTALITY — The overall mortality associated with duodenal injury has ranged from 5 to 30 percent [2]. Mortality increases with increasing grade of injury. Approximately one-half of deaths are early, caused primarily by bleeding and hemorrhagic shock, and one-half of deaths are late, due to complications including sepsis, fistula formation, and multiorgan failure [8]. The risk for death increases with associated pancreatic injury, associated bile duct injury, and delay in diagnosis [2,65,69]. The risk for late infectious complications is high even when the injury is identified early.
Mortality among patients who survive to receive trauma care appears to be similar for blunt compared with penetrating duodenal injury. In a review of 15 case series describing more than 1400 patients, the mortality rate attributed to duodenal injury was 14 percent for penetrating injuries and 18 percent for blunt injuries [8].
Complications of duodenal injuries — Duodenal injuries are associated with very high complication rates [2,27]. In a multi-institutional review of trauma registries, complications associated with duodenal injuries occurred in 27 percent [27]. Complications related to duodenal injury can include intra-abdominal abscess, duodenal fistula, and post-traumatic pancreatitis. Inflammatory changes and duodenal wall hematoma can also rarely cause late duodenal stricture.
Risk factors associated with complications following duodenal repair include blunt mechanism or high-energy missile injury, injuries involving more than 75 percent of duodenal circumference, injury of the first or second portion of the duodenum, common bile duct injury, and delay in repair greater than 24 hours [27,65].
●Intra-abdominal abscess – The most common complication of duodenal injury is intra-abdominal abscess, which occurs in 11 to 18 percent of patients [8]. Fluid collections are managed with antibiotics and percutaneous drainage. Reoperation is generally not needed.
●Duodenal fistula – The most life-threatening complication of duodenal injury is duodenal fistula, which occurs in approximately 7 percent of patients [8]. Management consists of drainage to control the fistula output, drainage of any associated intra-abdominal abscesses, broad-spectrum antibiotics, fluid therapy, and nutrition support. In patients who develop a high-output duodenal fistula, re-exploration should be considered if detected early but may not be feasible due to adhesions in the postoperative period [38]. (See "Enterocutaneous and enteroatmospheric fistulas".)
●Post-traumatic pancreatitis – Post-traumatic pancreatitis complicates duodenal injury in 3 to 15 percent of patients [8]. Management of post-traumatic pancreatitis is similar to the management of other forms of pancreatitis with bowel rest and nutritional support [70]. (See "Management of acute pancreatitis".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Traumatic abdominal and non-genitourinary retroperitoneal injury".)
SUMMARY AND RECOMMENDATIONS
●Incidence and risk – Traumatic injury to the duodenum is infrequent, occurring in 3 to 5 percent of patients with abdominal injury. Penetrating injury to the duodenum is more common overall, but blunt duodenal injury typically caused by motor vehicle crashes is more common in the United States. The second portion of the duodenum is most commonly involved, with injuries distributed equally for the other portions. Given its proximity to a number of structures, it is not surprising that the duodenum is rarely injured in isolation. (See 'Injury mechanism' above and 'Associated injuries' above.)
●Clinical features – Signs and symptoms (eg, abdominal pain, peritoneal signs) of duodenal injury are nonspecific and may be even less apparent in the retroperitoneal portion. Suspicion for duodenal injury should be increased with any direct blow or crushing impact to the abdomen, any implement that traverses the mid-to upper abdomen, or when injury to an adjacent organ is detected. (See 'Clinical evaluation' above.)
●Diagnosis – For hemodynamically stable patients, abdominal computed tomography (CT) is the initial imaging study to evaluate the duodenum. CT findings associated with duodenal injury include duodenal thickening, periduodenal fluid, extraluminal air, and heterogenous fluid (clot) accumulation near the site of injury. Low-grade duodenal injuries can be challenging to diagnose, and repeat abdominal CT may be needed. When exploratory laparotomy is indicated, the peritoneal portions of the duodenum should be directly examined for intramural hematoma or lacerations and retroperitoneum examined for air bubbles and hematomas. Hematomas related to penetrating injury should be explored. (See 'Diagnosis' above.)
●Duodenal injury severity and management – Management of duodenal injuries depends on the mechanism of injury (blunt or penetrating) and injury grade (table 4), which correlates with the presence of associated injuries and increasing rates of morbidity and mortality. Concomitant injuries may require more urgent attention necessitating a damage control approach for the duodenal injury. Damage control for duodenal injuries may involve closure or resection of the injured segment without reestablishing gastrointestinal continuity. (See 'Duodenal injury grading' above and 'Damage control' above.)
●Conservative management of duodenal hematoma – For hemodynamically stable patients with blunt grade I or grade II duodenal hematoma definitively identified on CT and with no other indications for abdominal exploration, we suggest initial conservative management, rather than duodenal intervention or repair (Grade 2C). Many duodenal hematomas identified during abdominal exploration can also be managed conservatively. Most conservatively managed duodenal hematomas resolve, although approximately 10 percent will require surgical decompression to relieve luminal obstruction. Conservative management includes bowel rest, nutrition support (enteral preferred), and gastrointestinal decompression for proximal bowel obstructive symptoms. Nonoperative management is not advised for penetrating duodenal injury. (See 'Role of conservative management' above.)
●Duodenal repair – When duodenal injuries require operative intervention, relatively simple surgical techniques are often all that are needed. These include debridement of devitalized tissue, local repair of lacerations, closed-suction drainage, and, for full-thickness duodenal injury, resection and primary anastomosis (duodenoduodenostomy), or duodenojejunostomy and Roux-en-Y reconstruction. Several adjunctive techniques (eg, pyloric exclusion, duodenal decompression, duodenal diverticularization) have been described to decrease the potential for leak following duodenal repair, but no studies have proven any benefit. (See 'Repair of duodenal injury' above and 'Adjunctive surgical techniques' above.)
●Combined duodenal and pancreatic injury – For combined injuries of the duodenum and pancreas, sometimes the duodenal injury and pancreatic injury can be approached separately with relatively simple procedures, but combined extensive injuries, which are overall uncommon, may require staged pancreaticoduodenectomy and interval reconstruction. (See 'Damage control' above and 'High grade' above.)
●Complications and mortality – Mortality following duodenal injury is related to the severity of the injury and associated injuries and is approximately 15 percent. Complications of duodenal injury are common and include intra-abdominal abscess, duodenal fistula, and post-traumatic pancreatitis. High rates of late infectious complications occur even if the injury is diagnosed and treated in a timely fashion. These complications can usually be managed without the need to return to the operating room. (See 'Morbidity and mortality' above.)
ACKNOWLEDGMENTS — The editorial staff at UpToDate acknowledges Ronald Jou, MD, and Susan I Brundage, MD, who contributed to earlier versions of this topic review.
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