The frequent coexistence of duodenal and pancreatic injuries has led to a combined classification of these injuries. However, Moore et al
. have classified isolated traumatic duodenal injuries[6
] and, as per their classification, our patient had a grade II injury.
Spontaneous duodenal diverticulum perforation has been reported earlier.[7
] Traumatic — as opposed to iatrogenic (e.g., endoscopic) — perforation is unusual. Adding to the uniqueness of this case is the absence of injury to any of the other organs. This relatively minor degree of trauma resulted in an isolated but significant and life-threatening injury, with pooling of activated digestive enzymes, likely including amylase, in the retroperitoneal space. Clinicians must have a low threshold for investigating patients following such minor trauma, and non-musculoskeletal causes must also be considered when managing traumatic back pain.
Blunt injury to the abdomen commonly affects the liver, spleen, and kidneys. Small bowel injury is also known to occur as a result of deceleration forces causing tears near fixed points of attachment. In our patient, we suspect that compression of the diverticulum at the point where it passes over the 2nd and 3rd lumbar vertebra occurred during deceleration, resulting in its rupture. The peritoneal attachments give anchorage to the first part of the duodenum and the duodenojejunal junction; in between these two points, the retroperitoneal duodenum is sandwiched between the pancreas, the right psoas muscle, the inferior vena cava, and the right kidney posteriorly, and only the transverse colon and the superior mesenteric vessels anteriorly. Thus, on impact, this duodenal diverticulum was compressed between the anterior and posterior structures, which likely resulted in its perforation. However, no injury occurred at the duodenal anchorage points. No injury was sustained to the right kidney or to its hilar vessels lying in close proximity.
Our surgical management of this patient is similar to that reported by other authors,[8
] though conservative management (for grade 1 injuries), gastrectomy with a Bilroth II gastrojejunostomy (for grade III injuries), and pancreaticoduodenectomy (for grades IV and V injuries) are also documented.[9
] It is possible that percutaneous drainage could have controlled the local sepsis and helped drain the active enzymes in the retroperitoneal space, but any attempts at conservative management would also run the risk of complications such as pancreatic and duodenal fistula formation and recurrence of the collections. Thus, conservative measures should probably be reserved for those not fit for major surgery or those with other significant injuries. Diagnostic laparoscopy does not appear to be better that other imaging modalities for detecting duodenal injury[10
] although in expert hands, following exploration of the retroperitoneal space, it may be possible to carry out laparoscopic Kocherization and subsequent duodenal repair with an omental patch. Alternatively, a direct anastomosis of a Roux-en-Y loop sutured over the duodenal defect in an end-to-side fashion could have been undertaken, particularly if the defect were large.[9
] Perioperative mortality for symptomatic duodenal diverticula ranges from 3% to 31%,[6
] and the morbidity is around 15%. In this patient, wound infection, incisional hernia, and gastrointestinal bleeding were the three complications that we came across following surgical repair. A duodenal injury and a time to surgery of greater than 18 h is an adverse prognostic factor,[12
] as are age, hypotension on arrival, a negative base deficit, a lower initial arterial pH, and an associated inferior vena cava injury.[13
Surgery for perforated duodenal diverticula is thus recommended in emergency presentations or for intractable symptoms only.[11