Duodenal Injury after Blunt Abdominal Trauma in Children: Experience with 22 Cases

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1 Annals of Pediatric Surgery, Vol 2, No 2, April 26, PP Original Article Duodenal Injury after Blunt Abdominal Trauma in Children: Experience with 22 Cases Mohamed E Hassan, Amira Waly, Wael E Lotfy Department of General Surgery, Pediatric Surgery unit, Faculty of medicine, Zagazig University, Egypt Introduction: The natural history and management of duodenal injuries in children are incompletely described. The aim of this study was to describe the relation between the mechanism of blunt trauma and the severity of duodenal injury, as well as evaluation of the diagnostic and treatment modules of blunt duodenal trauma (BDT) in order to improve the management of these injuries. Patients and methods: A retrospective chart review was conducted on children presenting with history of abdominal trauma presenting over a period of 6 years. Only patients who were diagnosed with duodenal injury were included. The patients were divided according to their initial clinical presentation into 3 groups: group I (n=11) with evidence of peritonitis, group II (n-5) with abnormal abdominal findings and group III (n=6) with no significant abdominal findings Results: Twenty-two patients were encountered. There were 15 males and 7 females, their age ranged from 6 months to 1 years. The mechanism of trauma was Road Traffic Accident (passenger or pedestrian) in 12 patients and Focal trauma to the abdomen in the remaining 1 Time to initial exploration in the 17 patients with duodenal perforations was less than 8 hours from admission in 7 patients, from 8-24 hours in 7 patients, from hours in 2 patients and one patient was explored after 55 hours of admission. Complications were encountered in 2 patients after surgical repair of duodenal injuries. Two patients died, however the cause of death was unrelated to the duodenal trauma. Conclusion: Although duodenal trauma in children is uncommon, the physician examining a child with upper abdominal symptoms must have a high index of suspicion for duodenal injury even in the absence of history of trauma. The lethal potential of duodenal trauma relates to the severity of the trauma, associated injuries, and the adequacy as well as expedience of treatment. Key Words: Blunt abdominal trauma, Children, Duodenum. D INTRODUCTION uodenal injuries in children are predominantly blunt. The natural history and management of pediatric duodenal injuries are incompletely described. 1 Diagnosis of duodenal and pancreatic injuries are frequently delayed, and optimal treatment is often controversial. 2, 3 The presentation of gastrointestinal perforation after blunt abdominal trauma in children can be subtle and at times delayed. 4. Delay in diagnosis or operative intervention for more than 24 hours is associated with increased complication rate and prolonged hospitalization. 1 A slight increase in the concentration of aspartate aminotransferase, alanine aminotransferase, and/or pancreatic enzymes may be the only indication of hollow viscus injury. Initial radiographic studies have a low yield in detecting such injuries. Computed tomography is also unreliable. Conservative management with serial examinations and serial laboratory studies may be required to identify gastrointestinal perforation. 4 The aim of this study is to report a 6-year experience with duodenal injuries in children in an attempt to find out a relation between the mechanism of blunt trauma and the severity of duodenal injury, Correspondence to: Mohamed E Hassan, Pediatric Surgery Unit, Faculty of Medicine, Zagazig University, 44511, Zagazig, Egypt. Mobile: Fax: Dmia88@hotmail.com

2 as well as evaluation of the radiological investigations, therapeutic management and the outcome of blunt duodenal trauma in order to improve management of these injuries. MATERIALS AND METHODS A retrospective chart review was conducted on children presenting with a history of abdominal trauma presenting at a single institution over period of 6 years. Only patients who were diagnosed with duodenal trauma were studied. Emphasis was placed on age and gender of patients, detailed mechanism of trauma, diagnostic modalities, time to initial surgical exploration and the reason for delay, associated injuries, extent of duodenal injury, operative repair, and complications directly related to the duodenal injury and the outcome. The patients were divided according to their initial clinical presentation into 3 groups: group I: with evidence of peritonitis, group II: with abdominal findings such as distension, minimal tenderness, and guarding, and group III: with normal abdominal findings. Diagnostic modalities included plain X-ray, Ultrasound, upper gastro-intestinal series, Computerized Tomography (CT), and exploration laparotomy. Duodenal injuries were classified using the Organ Injury Scale for the Duodenum into the following categories: a) intramural hematoma; b) intraperitoneal rupture; c) retroperitoneal rupture, and d) intra and retroperitoneal rupture. 5 Data were collected and analyzed. RESULTS Twenty-two patients were encountered in the study. This group included 15 males and 7 females, their age ranged from 6 months to 1 years with a mean age of 5.25 years (Table 1). The mechanism of trauma was Road Traffic Accident (RTA) (n=12; 9 patients were passengers and 3 were pedestrians). Focal trauma to the abdomen from bicycle handlebars, animal kick, or falls onto blunt objects were the causes in the remaining 1 patients (Table 2). Intramural hematoma was found in 4 patients, Intraperitoneal ruptures in 6 patients, retroperitoneal rupture in 6 patients and intra and retroperitoneal rupture in 6 Positive diagnostic tools that led to diagnosis of duodenal injuries were: Plain X ray with pneumoperitoneum in 3 patients (Fig 1). Ultrasound findings of duodenal hematoma in 2 Upper GI series findings of retroperitoneal leak in 2 patients (Fig 2), or intraperitoneal leak in 5 CT. findings of duodenal hematoma (n=3), retroperitoneal air (=2), or thickening of duodenal wall and leak in 3 patients (Fig 3). Exploration laparotomy was done in 2 patients (Table 3). Table 1. Age and gender distribution Variables Group I: Evidence Of peritonitis (N =11) Group II: Positive abdominal findings (N=5) Group III: Normal abdominal findings (N=6) 5 1 years Mean = 7.5 Age 6 months 5 years Mean = years Mean = 5.5 Gender Male Female 7(63.6%) 4 (36.4%) 3(6%) 2(4%) 5(83.3%) 1(16.7%) Annals of Pediatric Surgery 1

3 Table 2. Type and mechanism of duodenal trauma Type of duodenal injury Mechanism of injury Road traffic accidents Passengers Pedestrians Focal trauma Bicycle handle bar Animal kick Fall on blunt object Group I Evidence of peritonitis (N= 11) Group II Positive abdominal findings (N= 5) Group III Normal abdominal findings(n= 6) IPR IPR&RPR IMH RPR IPR IPR&RPR IMH RPR 3 (27.3%)* 3(27.3%) 1 (2%) 1(2%) 1(16.7%) 2(18.2%) 1(2%) 1(9%) 1(2%) 1(16.7%) 2(33.3%) 1(9%) 1(2%) 1(16.7%) 1(9%) 1(16.7%) Total 6(54.6%) 5(45.4%) 2(4%) 2(4%) 1(2%) 2(33.3%) 4(66.7%) IPR:Intra-peritoneal rupture, IMH: Intra- mural hematoma, RPR Retro-peritoneal rupture, *% of total number of patients in each group Table 3. Diagnostic modalities Diagnostic modalitie Plain X-Ray 3(27.3%)* Ultrasound Group I: Evidence of peritonitis (N =11) Group II: Positive abdominal findings (N=5) Group III: Normal abdominal findings (N=6) 2(33.3%) CT with IV & Oral contrast 2(18.2%) 3 (6%) 3 (5%) Upper GI series 5 (45.4%) 2 (4%) Exploratory laparotomy 1 (9.1%) 1(16.7%) *% of total number of patients in each group Table 4. Associated injuries Associated injuries Group I Evidence of Peritonitis (N =11) Group II Positive abdominal findings (N=5) Group III Normal abdominal findings(n=6) Associated intra-abdominal injuries Pancreatitis Intestinal injuries Splenic injury 2 (18.2%)* 2 (18.2%) 1 (9.1%) 1(2%) Associated Extra-abdominal injuries CNS Skeletal Thoracic 1 (9.1%) 1 (9.1%) 1(9.1%) 1 (2%) Total 8(72.8%) 2(4%) *% of total number of patients in each group 11 Vol 2, No 2, April 26

4 Table 5. Relation between type of duodenal injury and the surgical management Variables Group I Evidence of peritonitis (N= 11) Group II: Positive abdominal findings (N= 5) Group III: Normal abdominal findings (N= 6) IPR IPR&RPR IMH RPR IPR IIPR&RPR IMH RPR Duodenorrhaphy 5 (45.5%) 1(9.1%)* 1 (2%) 2(33.3%) Duodenal repair, Duodenostomy tube & feeding jujenostomy 2 (18.2%) 1 (2%) 1 (2%) 1(16.7%) Duodenojujenostomy 1 (9.1%) 1 (9.1%) 1(16.7%) Duodenojujenostomy & pyloric exclusion Conservative treatment 1 (9.1%) 2 (4%) 1 (16.7%) Drainage of Hematoma 1 (16.7%) Total 6 (54.5%) 5 (45.5%) 2 (4%) 2 (4%) 1 (2%) 2 (33.3%) 4(66.7%) IPR: Intra-peritoneal rupture, IMH: Intra- mural haematoma, RPR Retro-peritoneal rupture, *% of total number of patients in each group Seventeen of the 22 patients had duodenal perforation. The time needed for reaching the correct diagnosis of duodenal perforation and surgical intervention varied between patients according to their clinical presentation at time of admission. It was less than 8 hours from time of admission in 7 cases, from 8-24 hours in 7 cases (one patient of them had negative trauma history preoperatively, mechanism of trauma was focal blow by bicycle handlebar and operative findings revealed retroperitoneal rupture) and from hours in 2 cases (both of them had negative trauma history preoperatively). One of them had inconclusive initial clinical presentation. Rising white cell count and fever after 24 hours of admission as well as high output naso-gastric tube bilious drainage and plain X-ray suspicious of free retroperitoneal air, led to the diagnosis. The other case showed retroperitoneal contrast leak in CT after normal plain X-ray and ultrasound at initial work up. Both cases revealed retroperitoneal duodenal rupture intra-operatively. One patient was explored after 55 hours of admission. He was presented with epigastric discomfort and no history of trauma was given. Initial clinical examination was inconclusive as well as laboratory, plain X-ray and ultrasound. On the second day of admission, resumption of oral feeding was started but not tolerated and mild upper abdominal tenderness started to appear, at this time the investigations were repeated but were reported as normal. H 2 blockers were started as a suspicion of gastritis was raised but on the 3rd day of admission upper abdominal tenderness was increasing and at that time decision to explore the child was taken after the parents gave consent. Intra-operative findings revealed retroperitoneal duodenal rupture. The other 4 patients with diagnosis of duodenal hematoma were treated conservatively except only one patient who did not respond to conservative treatment and laparotomy was done on the 8th day of admission to drain the hematoma. Associated injuries: Associated intra-abdominal injuries: pancreatitis (n=2), small intestinal injuries (n=2), minor splenic tear (n=1), and ceacal perforation (n=1). Associated extra-abdominal injuries: central nervous system injury in 1 patient (intracerebral hemorrhage); skeletal system injury in 2 patients (1 fracture clavicle and 1 fracture radius) and thoracic injury in 1 patient (heamothorax treated by intercostal tube) (Table 4). Annals of Pediatric Surgery 12

5 Treatment modalities varied according to the type of injury (Table 5): Primary duodenorrhaphy was done in 9 Primary duodenal repair with duodenostomy tube and feeding jujenostomy were done in 5 Duodenojejunostomy was performed in 3 Pyloric exclusion in 1 patient. Laparotomy and drainage of the duodenal hematoma after failure of conservative treatment in one patient. Fig 1. Plain erect X-ray suspecting retroperitoneal air at right upper and lower abdominal quadrant. Fig 2. Upper GI series showing a leak from the third part of duodenum Two complications were encountered after surgical repair of duodenal injuries in (2/19, 1.5%). One patient developed duodenal fistula, which was managed conservatively. The other patient developed dehiscence of the duodenal repair in the 3 rd postoperative day. Re-exploration was done and pyloric exclusion with gastrojujenostomy was created. The patient discharged after one-month hospital stay in good general condition. The overall encountered mortality was 2 cases. However, none of them was directly related to the duodenal trauma. The first mortality occurred in a 3- year old girl who was a passenger in a motor vehicle crash and presented with intracerebral hemorrhage, cecal and duodenal perforations. The other was a 6- year old boy who fell from the second floor and presented with peritonitis and post concussion. Abdominal exploration revealed intra and extraperitoneal rupture of the 3 rd part of duodenum and normally looking pancreas, duodenorraphy and gastrojujenostomy were done. On the 4th postoperative day, there was fever of 39 C, white blood cells of 2ml, CT abdomen revealed peripancreatic collection that was drained under CT guidance. However, the child developed severe respiratory distress that required mechanical ventilation and there was high serum lipase level as well as progressive hypocalcaemia. In spite of aggressive medical management, the child died after 1 days of admission due to pancreatitis. Fig 3 Enhanced CT of the abdomen showing free intraperitoneal fluid and thickening of the wall of the third part of duodenum. 13 Vol 2, No 2, April 26

6 DISCUSSION The Duodenal injury secondary to blunt trauma continues to pose a diagnostic challeng. 6 The findings on initial physical examination and CT evaluation can independently identify the presence of intestinal injury (including duodenal) in approximately 25% of cases. In the remainder of cases, the awareness of the more subtle findings of bowel injury on a CT scan can complement the physical examination findings and potentially lead to a more timely intervention for bowel injury. 7 Males were double numbers of females in this study which may be attributed to the increased activity and hence more liability to trauma exposure in males than females. In addition, the age range in group I (with evidence of peritonitis) was lower than that in groups II and III, which confirm that extremes of age are more prone to the effect of trauma. Trauma caused by road traffic accidents was the most severe type of trauma and was associated with more multiple injuries and death. Children in this group had higher injury severity scores (ISS) than other trauma groups; this is in accordance to Shilyansky et al results. 8 On the other hand, trivial unnoticed trauma by the parents causing duodenal trauma was a major issue in this study that lead to delay in the diagnosis in cases presented with vague abdominal symptoms and signs. After establishing the diagnosis of duodenal injury in vague cases, tracing any trauma history from the parents was positive in 4 cases (18%). The parents attributed their reluctance to mention the history of trauma that they did not consider this type of trauma significant enough to be mentioned to the medical team. All patients with negative initial medical history for any trauma, proved to have retroperitoneal rupture. These findings raise the idea that duodenal trauma should always be in the differential diagnosis of any pediatric case presented with vague upper abdominal symptoms and signs without obvious cause even in absence of trauma history. Pokorny et al stated that it is not unusual for a child with retroperitoneal duodenal injury to be sent home from the emergency center after what is thought to be a trivial abdominal injury only to return with abdominal pain. Frequently, the pain localizes to the right lower quadrant and may be confused with appendicitis". 9 The current study substantiates the previous statement. The issue of child abuse (maltreatment) should also be excluded in of children with blunt abdominal injury with unidentified trauma history, 1 although this was not proven as a cause of trauma in our study. Radiological diagnostic modalities aided in the proper diagnosis, the CT abdomen with IV and oral contrast was the most helpful, especially in differentiating cases with duodenal perforation from those with hematoma only. The detection of retroperitoneal air and/or contrast extravasations on CT was crucial for proper management. 7 Ultrasound was the least helpful diagnostic aid in this study. This may be attributable to the high operator dependant rate in ultrasound, 11 in addition to lack of a particular radiologist assigned for ultrasound interpretation in the study. Children with diagnosis of duodenal hematoma were treated expectantly, while those with duodenal perforations were treated surgically. A 75% of cases with duodenal hematoma were successfully managed conservatively; this is in accordance to the established management of this type of duodenal trauma Forty one percent of patients with duodenal perforations were explored within 24 hours of admission, 12 % of patients were explored within hours of admission, while 6% only were explored within hours of admission. Retrospective analysis of the causes of delay were mainly due to initial vague abdominal clinical signs as well as absence of trauma history. This delay did not affect the outcome in our study as both postoperative mortality and morbidity occurred in the group of patients diagnosed within 48 hours of admission. Six intra-abdominal versus 4 extra-abdominal associated injuries were encountered in our study, which was related to the severity of the mechanism of trauma. The surgical management of duodenal trauma was chosen according to the intraoperative findings. In accordance to Shilyansky et al, 8 tear in duodenal wall with healthy looking adjacent duodenal wall and no other GIT injuries, was repaired by primary duodenorrhaphy, while additional procedures were reqiured in cases associated with GIT injuries and/ or when the surrounding tissues looked unhealthy. Annals of Pediatric Surgery 14

7 The complication rate in this study was 1.5% (2/19) which was managed properly and no deaths occurred. Snyder et al reported a complication rate of 9% in his study. 15 One case of postoperative duodenal fistula managed conservatively by parental nutrition, somatostatin and local wound care, which led to closure of the fistula in 1 days. It is worth to mention that this case was treated initially by primary duodenorrhaphy without duodenostomy tube drainage that support Shilyansky et al 8 report of high incidence of postoperative duodenal fistula in cases treated without duodenostomy tube drainage. However, larger scale studies are required to prove or disprove this finding. The other case was dehiscence of duodenal repair that required re-operation and addition of pyloric exclusion and gastrojujenostomy. The 9 % mortality rate in this series (2/22) was not directly related to duodenal injury, but was attributed to associated head trauma and pancreatic injury. This highlights the impact of other associated injuries on the final outcome of patients with duodenal injuries and mandates the availability of a designated trauma team. CONCLUSION Although duodenal trauma in children is uncommon, the physician examining a child with upper abdominal symptoms must have a high index of suspicion for duodenal injury even in the absence of trauma history. The lethal potential of duodenal trauma relates to the severity of the trauma, associated injuries, and the adequacy as well as expedience of treatment. REFERENCES 1. Clendenon JN, Meyers RL, Nance ML, et al: Management of duodenal injuries in children. J Pediatr Surg 39: , Sriussadaporn S, Pak-art R, Sriussadaporn S, et al: Management of blunt duodenal injuries. J Med Assoc Thai 87: , Plancq MC, Villamizar J, Ricard J, et al: Management of pancreatic and duodenal injuries in pediatric Pediatr Surg Int 16:35-39, 2 4. Barandica R, Patel M: Pediatric duodenal perforation missed on computed tomography. Ann Emerg Med 3: , Moore EE, Cogbill TH, Malangoni MA, et al: Organ injury scaling. Surg Clin N Am 75:293 33, Desai KM, Dorward IG, Minkes RK, et al: Blunt duodenal injuries in children. J Traum 54:64-645; discussion , Kurkchubasche AG, Fendya DG, Tracy TF Jr, et al: Blunt intestinal injury in children. Diagnostic and therapeutic considerations. Arch Surg 132: ; discussion , Shilyansky J, Pearl RH, Kreller M, et al: Diagnosis and management of duodenal injuries in children. J Pediatr Surg 32:88-886, Pokorny WJ: Abdominal trauma in: Raffensperger JG (ed): Swenson s Pediatric Surgery (5th Ed.), Appleton and Lange, Norwalk, Connecticut, USA, 199, pp: Reece RM: Unusual manifestations of child abuse. Pediatr Clin N Am 37:95-921, Old JL, Dusing RW, Yap W, et al: Imaging for suspected appendicitis. Am Fam Physician 71:71-78, Jewett TC Jr, Caldarola V, Karp MP, et al: Intramural hematoma of the duodenum. Arch Surg 123:54-58, Voss M, Bass DH: Traumatic duodenal hematoma in children. Injury 25:227-23, Touloukian RJ: Protocol for the nonoperative treatment of abdominal trauma during childhood. Am J Surg 145:33-334, Snyder WH 3rd, Weigelt JA, Watkins WL, et al: The surgical management of duodenal trauma: Precepts based on a review of 247 cases. Arch Surg 115: , Vol 2, No 2, April 26