TRAUMA 1

A 34-year-old male patient is brought to you after his friend’s car was involved in a collision. The patient was in front passenger seat, wearing a seat belt, and complains of epigastric pain since the event. He is hemodynamically stable with no obvious injury or complaint, other than epigastric pain. X-ray of the abdomen shows retroperitoneal air. Which of the following is the investigation of choice to confirm the suspected diagnosis?
A. Plain CT scans of abdomen
B. Diagnostic peritoneal lavage
C. Exploratory laparotomy
D. CT scans of abdomen with oral contrast
E. USG of abdomen

Explanation:
Twenty to thirty percent of duodenal injuries follow blunt trauma, when the duodenum is compressed between the spine and an external solid structure like a steering wheel, lap belt (as in this case), etc. The second portion of the duodenum, being retroperitoneal and the least mobile, is most commonly injured.

Isolated duodenal injuries can be easily missed. Patient may complain of epigastric or right upper quadrant pain, with or without peritoneal signs; however, presentation may be very subtle and requires a high degree of suspicion for diagnosis. Retroperitoneal air or obliteration of right psoas margin on abdominal x-ray is very suggestive. CT scan of the abdomen, with administration of oral contrast material, confirms the diagnosis of duodenal injury. If CT scan is not available, upper GI study with gastrograffin, and if negative, with barium can be used.

(Choice A, E) Plain CT scan of the abdomen and USG are not sensitive for duodenal injuries, though they would diagnose the associated injuries.

(Choice B) DPL is not sensitive for duodenal injuries, as the second part of the duodenum is the most commonly injured portion and is retroperitoneal.

(Choice C) The patient is hemodynamically stable with no signs of penetrative abdominal injury; so, exploratory laparotomy is not warranted.