Surgical paper V
Diagnosis and treatment of closed retroperitoneal duodenal injury
A Case Report
A 29-year-old male was admitted to our hospital one hour after experiencing a traumatic impact to his right rib area when his bicycle collided with the handle of a parked scooter. He reported immediate severe pain, difficulty breathing, and palpitations.
Initial Examination and Admission
Upon admission, the patient’s vitals were as follows: Blood Pressure 15/10 kPa, Temperature 36°C, Pulse 68 beats/min. He appeared alert but in acute pain. Physical examination revealed a shallow abrasion along the clavicular midline of the right costal margin, a slightly tense right upper abdominal muscle, and no obvious tenderness or rebound pain. Abdominal puncture was negative. Laboratory tests indicated Hemoglobin levels at 125 g/L, WBC count at 10.2 x 10^9/L, with 75% neutrophils and 25% lymphocytes. B-ultrasound showed no abnormalities in the liver, spleen, pancreas, or kidneys, and no abdominal fluid was detected. Chest fluoroscopy was also normal.
After 16 hours of hospitalization, the patient experienced increasing right-sided lumbar and testicular pain. Further imaging revealed indistinct fat lines and psoas major muscle shadows on the right side of the abdominal wall, although the right kidney appeared normal. Despite rehydration and anti-inflammatory treatments, the patient’s abdominal pain worsened.
Clinical Observations and Diagnosis
Subsequent physical examination showed increased abdominal muscle tension, widespread tenderness, particularly in the lower right quadrant, and rebound pain. Percussion of the right kidney area was painful. Repeat abdominal puncture and lavage were negative. Serum amylase levels were within normal limits, and WBC count was 11.1 x 10^9/L with 84% neutrophils and 16% lymphocytes. Urinalysis was negative. The patient was diagnosed with a closed retroperitoneal duodenal injury and underwent exploratory laparotomy 28 hours post-injury.
Diagnostic Challenges and Characteristics
Retroperitoneal duodenal injuries are rare and serious abdominal traumas that often present diagnostic challenges due to their initially subtle symptoms. Characteristic symptoms such as right lumbago and testicular pain may occur as a result of stimulation of the right psoas major muscle and retroperitoneal testicular nerve by duodenal fluid. Additionally, the accumulation of extraintestinal air in the retroperitoneal space can make the outline of the right kidney clearly visible in X-ray examinations. Elevated levels of serum amylase can also indicate the overflow of pancreatic juice. Diagnostic abdominal puncture is a valuable tool for early diagnosis, and some practitioners successfully use intraoperative injection of methylene blue via a stomach tube for diagnosis.
In this particular case, the patient exhibited symptoms of right lumbago, testicular pain, and signs of peritoneal irritation. Radiological findings revealed indistinct fat lines and psoas major muscle shadows on the right abdominal wall, while the right kidney outline remained clear. These factors led us to suspect a retroperitoneal duodenal injury. Exploratory laparotomy confirmed a retroperitoneal hematoma and diffuse green staining, corroborating our diagnosis.
Surgical Management and Postoperative Care
Despite the delayed surgery occurring 28 hours post-injury and considerable local inflammation, the patient experienced no postoperative complications. The surgical approach included gastrojejunal bypass, common bile duct drainage, and duodenal stump fistulization, supplemented by abdominal double cannula negative-pressure drainage.
Postoperatively, we implemented a range of adjuvant treatments aimed at patient recovery. These included continuous gastrointestinal decompression and duodenal fistula to lower duodenal internal pressure and minimize the retention of irritating and inflammatory fluids. We also administered a combination of broad-spectrum antibiotics and provided rehydration to maintain water, electrolyte, and acid-base balance. Active postoperative support was instrumental in the patient’s successful recovery.
This article was originally published in Transportation Medicine 1995. Vol.9, No.3 Changhang Hospital, Zhang Qi, Director: Li Mingjie