Duodenal tear following blunt (non-penetrating) injury- (A case report)SD Deodhar, VG Mehendale, GB Pallod, RS Rege
Department of Surgery, K.E.M.Hospital and Seth G. S. Medical College, Parel, Bombay-400 012, India
A case of rupture of retroperitoneal portion of duodenum following blunt trauma is reported and the relevant literature is reviewed.
Wounds of the duodenum, penetrating or non-penetrating, are rare. We recently treated a case of duodenal injury following blows to the anterior abdominal wall. The rarity of this condition prompted us to report it.
S.R., a 22 year old woman, was admitted to the King Edward VII Memorial Hospital on 21st September 1977 with upper abdominal pain, vomiting and pain in both the shoulders for four days. The symptoms had started following fist blows to the anterior abdominal wall.
On examination of the abdomen, there was generalised tenderness, guarding and distension; peristaltic sounds were feeble. The pulse rate was 120/minute and the blood pressure was 120/80 min of Hg. The rest of the examination did not reveal any abnormality. Radiological examination showed a large collection of free gas under the diaphragm. The intestinal loops were also grossly distended See [Figure 1] on page 192A.
With a clinical diagnosis of perforative peritonitis (due to ? duodenal perforation), the abdomen was explored under intratracheal gas oxygen anaesthesia, after about two hours of admission. Prior to the operation, nasogastric suction, intravenous fluids and antibiotics were commenced.
On opening the abdomen, free gas immediately escaped. A well localised abscess about 7.5 x 7.5 cms was found between the hepatic flexure of the colon and the inferior surface of the liver. There was a small hole in the anterior wall of the abscess cavity from which bile and faeculent matter continued to leak into the peritoneal cavity. Further exploration of the abscess cavity revealed necrosis of the anterolateral wall of the second part of the duodenum, leaving a rent of 3.75 x 2.5 cms. The liver, the right kidney and the colon were normal. Attempts to close the rent in the dhodenum failed. So a free omental graft was overlaid on the rent and fixed to the healthy duodenum above and below. A protective retrocolic, isoperistaltic gastrojejunostomy was carried out, a tube drain was left in the hepatorenal pouch and the abdominal wall was closed in layers.
During the post-operative period, intravenous fluids, antibiotics and nasogastric suction were continued. Three units of whole blood were transfused. Her condition was critical for the first 48 hours. But, after that she rallied round. The drain in the hepato-duodenal pouch used to produce between 700 and 800 ml. of bilious fluid per day for the first six days. After that, the quantity of the fluid rapidly dropped to 200 ml per day. The drain was removed on the 16 th post-operative day, when the discharge had be come small in quantity. Oral feeding was commenced on the 6th day, and was gradually built up. The diet was fortified by giving extra proteins and carbohydrates. The initial weight loss was 3 kg. But this was made good by the time of discharge from the hospital. Thrombophlebitis at the site of venesection and mild urinary sepsis responded well to treatment. She was discharged on the 30th post-operative day with slight discharge from the tube track.
Micrografin study of the upper gastrointestinal tract, done after 6 weeks, showed adequately functioning gastrojejunal stoma; some dye did enter the proximal duodenum forming a small pocket in the operated area. X-ray of abdomen taken one week after micrografin study, showed complete disappearance of the dye [Figure 2] and [Figure 3] on page 192A.
Wounds of the duodenum may be either penetrating or non-penetrating. Penetrating wounds usually follow war injuries and in one series constituted 3.7 per cent of all abdominal injuries. 
Non-penetrating wounds of the duodenum as a result of blunt trauma occur even more infrequently; hence, most papers consist usually of a single case report. Morton and Jordan  estimate that duodenal wounds occur in 4-5 per cent of all patients with abdominal injuries. Ten per cent of all non-penetrating ruptures of the intestines affect the duodenum .  Eighty per cent of the injuries in the case of closed rupture of duodenum are in the second part of the duodenum .  Cooke and Southwood  in a series of 200 cases of closed abdominal injuries could not find a single case with duodenal injury.
On reviewing the Indian literature, we were able to locate two reports. Deodhar et al  in 1968 reported two cases and Vyas et al  reported two more cases in 1970.
Mechanism of Injury
These have been discussed in detail by Cocke and Meyer  and Deodhar et al. 
In brief they are:
1. Crushing of the duodenum against the vertebral column as in automobile accidents, blows on the abdomen or a fall from height. In this type of injury, surprisingly, the neighbouring pancreas and the mesenteric vessels usually escape injury.
2. A tangential or a shearing force applied to the duodenum. However, Cocke and Meyer  do not agree with this.
3. Closed loop type of injury in a gas filled duodenum, supposed to be responsible for most of the cases of ruptured duodenum. This is in agreement with Jones. 
A pressure of 14 mm Hg is needed to rupture the small intestine in man, and this is easily generated in a closed loop of duodenum by a localised force. 
4. Fish and Johnson  suggested that compression of costal arches driving liver upwards causes traction on hepatoduodenal ligament and common bile duct and produces injury to the duodenum.
The diagnosis is essentially based on a history of a severe abdominal blow followed by sudden pain. The pain usually passes relatively soon and is followed by a period of quiescence. Later on as peristalsis develops, the pain returns and is usually generalised and is accompanied by tenderness. Shock is not common, but may occur later. With the passage of time the pulse rises rapidly and signs of free fluid in the peritoneal cavity may appear. Subcutaneous emphysema of the neck has been reported. 
X-ray examination may show gas beneath the diaphragm after a few hours; in some cases the gas may be seen within the tissue planes, outlining the right kidney. Oral gastrografin may help to confirm the diagnosis. 
As in the case of urinary bladder,  with a retroperitoneal organ like the duodenum, signs of peritonitis should not be awaited, because they may never occur. After due preparation a thorough exploratory laparotomy through an adequate incision becomes mandatory. It is wise to remember Turner's  comment, "Patients will not die from a very big incision but may very likely succumb if some important injury is overlooked". Small tears can be closed in two layers. If there is a tear in the second part, a choledochotomy and `T' tube drainage of the common bile duct are advisable. A complete transection may be treated by end-to-end suture, provided there is no great loss of continuity of the posterior wall. If this loss has occurred a loop of proximal jejunum may be brought up and anastomosed into the laceration. Some authors  recommend closure of both ends and a gastroenterostomy. In such cases duodenojejunostomy may be a wise procedure.
Early deaths are usually due to haemorrhage and shock. Peritonitis, pancreatitis, external duodenal fistula, subdiaphragmatic abscesses and duodenal stenosis following suture, all contribute to the high mortality.
[Table 1] shows the reported mortality figures. It indicates a gradual improvement in mortality figures over the years.
We are thankful to the Dean, K.E.M. Hospital, Bombay, for allowing us to report the case. We are also thankful to the members of the nursing staff and resident medical staff for help in the care of the patient.
[Figure 1], [Figure 2], [Figure 3]