Duodenal injury

Introduction to duodenal injury Duodenal injury is a serious intra-abdominal injury, accounting for about 3 to 5% of intra-abdominal injuries. The duodenum is adjacent to the liver, gallbladder, pancreas and large blood vessels. Therefore, duodenal injury often involves one or more organ damage. basic knowledge The proportion of illness: 0.002% Susceptible people: no special people Mode of infection: non-infectious Complications: intestinal fistula

Cause of duodenal injury

(1) Causes of the disease

There are two main causes of duodenal injury, namely abdominal trauma and iatrogenic injury. The former is divided into two categories: closed injury and open injury. The latter is often due to endoscopy and treatment and right hemicolectomy, cholecystectomy. Surgery, right kidney resection and other injuries caused by surgery.

The mechanism of closed duodenal injury caused by abdominal contusion is generally considered to be caused by external force directly pressing the duodenal tube on the lumbar vertebral body. The injured part is mainly the duodenal descending part, in the twelve fingers. At the junction of the intestine and jejunum, the duodenum is in a fixed position, and the jejunum connected to it is free. When the upper end of the jejunum is suddenly pulled when injured, the shear force generated causes the rupture of the distal end of the duodenum. It is believed that the duodenal jejunum is an acute angle. When the pyloric sphincter is closed, the duodenum may become a closed sputum. The external force acts on the intestinal tract to cause a sudden increase in pressure in the lumen, causing the bowel to burst.

(two) pathogenesis

The duodenum is exposed to different degrees of external force and can exhibit different types of damage:

Lighter forms a hematoma for contusion of the intestinal wall. Hematoma between the duodenum may exist under the mucosa, intramuscular or subserosal, most commonly under the serosa, larger hematoma can block the duodenum, clinically appear High intestinal obstruction symptoms such as vomiting of bile lead to dehydration and electrolyte imbalance.

In severe cases, the perforation is ruptured. Since the first half of the duodenum is in the abdominal cavity and the second half is in the peritoneal cavity, the ruptured perforation can occur in the abdominal cavity, or it can occur in the peritoneum, and the rupture and perforation occurs in the abdominal cavity. A large amount of intestinal contents overflow into the abdominal cavity, causing peritonitis, clinical symptoms and signs are obvious; rupture and perforation occurring in the extraperitoneal space, causing infection of the retroperitoneal space, clinical symptoms and signs are not obvious or delayed, pancreas and hepatic bile duct The anatomical relationship often involves injury, and some cases can damage the duodenal large blood vessels and cause massive hemorrhage. Many of the above reasons can cause shock in the patient.

Duodenal injury prevention

Prevent trauma and iatrogenic injuries.

Duodenal injury complications Complications, intestinal septicemia

1. Duodenal fistula is a common serious complication after duodenal injury. According to the statistical incidence rate of about 50%, its occurrence and missed diagnosis and treatment, improper operation, anastomotic blood circulation or tension and duode Infection around the intestine and other factors, mostly occurred 5 to 7 days after surgery, once accompanied by abdominal or retroperitoneal infection and sepsis, the mortality rate is as high as 50% to 70%.

2. Obstruction of duodenal injury caused by stenosis after suture, mainly manifested as vomiting.

Symptoms of duodenal injury Common symptoms Changchang abdominal muscles Tension abdominal pain Abdominal pain Subcutaneous emphysema Abdominal tenderness Nausea upper abdominal pain

The clinical manifestations vary depending on the extent of the injury and the presence or absence of a composite injury.

Abdominal duodenal rupture, clinical manifestations are obvious, mainly sudden severe abdominal pain, with the right side as the weight, accompanied by nausea, vomiting, with the increase of peritoneal exudate and peritonitis, bloating and stopping Qi, upper abdominal tenderness and abdominal muscle tension, bowel sounds disappeared, liver dullness moved down.

Hematoma of the duodenal wall, the clinical manifestations are generally mild in the early stage, the above abdominal pain and tenderness are the main, followed by obstructive symptoms, repeated biliary vomiting, with the increase of vomiting may appear water and electrolyte and acid-base balance Disorder, if the huge hematoma after trauma to compress the second and third segments of the duodenum, extensive necrosis and perforation of the duodenum may occur.

The rupture of the extraperitoneal duodenum often occurs after severe blunt trauma of the upper abdomen. It may temporarily lose consciousness, but it will recover after a few minutes. There is no special discomfort. It can even continue to move and work. After a period of time, it gradually feels continuous. Sexual abdominal pain, and may have nausea, vomiting, vomiting, blood, abdominal pain is generally confined to the right upper abdomen or back, and gradually worsened, because the retroperitoneal testicular nerve and the sympathetic nerve accompanying the spermatic artery are stimulated by intestinal effusion, even Testicular pain and penile erection can occur, physical examination of the right upper abdomen or back tenderness, and subcutaneous emphysema, early mild abdominal distension, abdominal muscle tension is not significant, bowel sounds weakened or disappeared, body temperature, pulse, breathing in There was no major change in the initial stage, but as the disease progressed, the above clinical manifestations gradually increased or became obvious. Even the tenderness may extend to the right kidney area, the inner edge of the right lumbar muscle, and the right abdomen slamming voice gradually expanded.

Duodenal injury examination

1. Blood routine White blood cell count is elevated.

2. Serum amylase is elevated.

3. Diagnostic abdominal puncture or lavage If the light yellow biliary fluid is withdrawn, it is mostly duodenal or biliary tract injury.

4. X-ray inspection

(1) Abdominal X-ray plain film: see the free gas under the armpit, the shadow of the psoas muscle is blurred, the duodenal cavity, the free gas and/or liquid in the right anterior interphalangeal space are clustered, and the shadow of the right kidney is blurred. Digestive diploid, more can be clearly diagnosed, but early X-ray film is difficult to find its typical X-ray performance, duodenal rupture, abdominal epidural can be seen on the plain film, gas accumulation around the right kidney and psoas muscle Gas often enters the transverse mesenteric membrane. In order to avoid confusion with the gas in the transverse colon, multiple times of filming can be taken at regular intervals. If the gas is accumulated in the transverse colon mesente, the position of the gas changes little; if the film is taken 24 hours after the injury, The gas can expand extensively behind the retroperitoneum, sometimes extending both sides down to the pelvis and up to the mediastinum.

(2) When the duodenum ruptures, the gas often enters the transverse mesentery. In order to avoid confusion with the gas in the transverse colon, multiple times can be taken at regular intervals. If the gas is accumulated in the transverse colon mesente, the position of the gas does not change much. ;

5. Digestive angiography

For patients with milder disease and unclear diagnosis, oral water-soluble contrast agents can be used for duodenal angiography. The diagnosis can be made clear. If the duodenum is ruptured, the contrast agent can be seen after injecting the water-soluble contrast agent through the gastric tube. It overflows from the rupture port.

6. Duodenal examination

If the diagnosis cannot be confirmed, and the condition is allowed, the feasible duodenoscopy is helpful for definite diagnosis.

7.CT scan

Some authors have reported that the early diagnosis of retroperitoneal duodenal rupture with abdominal CT scan is more sensitive than ordinary X-ray films, and it can be considered as a means of early diagnosis. Its CT features are: outside the duodenum, in front of the right kidney. Free gas or fluid accumulation in the gap, blurred shadow in the right kidney, duodenal dilatation, contrast agent can be interrupted without entering the distal duodenum.

Diagnosis and identification of duodenal injury

diagnosis

For the diagnosis of duodenal injury, especially retroperitoneal injury, it is difficult to misdiagnose and miss diagnosis, and to diagnose the duodenal injury, not only to determine whether it is damaged or not, but also to determine the serious damage. The extent and combination of other organ damage is of great significance to the patient's choice of treatment and surgical approach.

Preoperative diagnosis

(1) intra-abdominal rupture of the duodenum:

After abdominal trauma, if the duodenum is ruptured intraperitoneally, bile, pancreatic juice, duodenal juice and the like flow into the abdominal cavity, causing severe peritonitis, even fat necrosis, and signs of peritonitis and signs of systemic infection, thus diagnosis It is easier, but it should be noted that some patients may have symptoms relieved after the early severe abdominal pain, and even the abdominal pain disappears. It is called intermediate remission period. The possible reasons are: perforated intestinal wall muscle contraction, intestinal mucosa prolapse Prevent the intestinal contents from continuing to overflow. If the intestinal contents flowing into the abdominal cavity are neutralized by the peritoneal exudate and diluted, the peritoneal stimulation is alleviated, but as the disease progresses, the bacterial peritonitis gradually forms and the abdominal pain progresses progressively. Symptoms of systemic poisoning are becoming more apparent.

(2) Duodenal extraperitoneal rupture:

Any history of upper abdominal trauma, slow right upper abdominal pain, especially back pain and vomiting, and peritoneal irritation is not obvious, should consider the damage of the retroperitoneal organs, such as vomit blood, no clinical manifestations of kidney damage (hematuria, sputum pain in the kidney area, etc.), may be duodenal retroperitoneal rupture, if subcutaneous emphysema is found, the evidence of clinical diagnosis is more clear, and sometimes X-ray abdominal pictures show accumulation of gas in the retroperitoneal tissue, clearly displayed Out of the kidney outline, or a more transparent area along the vertebra to the medial end of the ankle, the shadow of the psoas muscle is blurred. If these X-ray signs are found, the diagnosis can be basically confirmed, but the negative result can not rule out the rupture of the extraperitoneal part of the duodenum. The barium meal examination is generally not used in the diagnosis of duodenal rupture, and oral iodine angiography may be used if necessary.

(3) Hematoma between the duodenum:

Is a special type of injury, the diagnosis is more difficult, the main signs are the pain in the upper abdomen after injury, nausea, with the increase of hematoma, may occur high intestinal obstruction or bile duct, pancreatic duct obstruction, etc., the right upper abdomen may be For the block, the meal can be found to have a more specific "screw spring sign", B-ultrasound, CT scan and other imaging examinations can help diagnose.

Pediatric rupture caused by penetrating abdominal trauma often requires open exploration to confirm the diagnosis. Pi Shoumin collected 16 cases of duodenal trauma in the past 10 years. It was confirmed by B-ultrasound, CT or laparotomy. Intra-abdominal rupture of the two fingers (18.75%), 8 cases (50%) of extraperitoneal rupture, 2 cases (12.5%) of duodenal wall hematoma, and 3 cases of duodenal rupture caused by penetrating trauma (18.75%), all of the 3 cases were expelled by laparotomy, and the rupture caused by duodenal penetrating injury was confirmed during the operation.

In short, the type of duodenal injury is different, and its clinical manifestations are quite different. When there are combined injuries including intra-abdominal organs and organs outside the abdomen, the signs of duodenal injury are often concealed, which makes clinical diagnosis difficult, and the following signs are summarized. Check for diagnosis that contributes to duodenal injury:

1 abdominal penetrating injury, bile-like outflow from the wound; closed injury in the neck, underarm, upper chest, back and rectum, sputum and sputum pronunciation and subcutaneous emphysema.

2 After abdominal trauma, the abdominal signs are relatively mild and the general condition is worsening or accompanied by blood, and the urine amylase is elevated.

3 Abdominal plain film is found in the retroperitoneum, diaphragm angle, right kidney, lumbar vertebrae or biliary tract; the waist muscles are blurred, but the kidneys are clear.

4 Gastrointestinal gas injection test found that abdominal or retroperitoneal gas or gastrointestinal aqueous solution examination, from the outside of the duodenal cavity.

5B ultrasound, CT scan and other imaging examinations or laparoscopy applications can further assist in the diagnosis.

2. Exploratory laparotomy

For patients with suspected duodenal injury, due to unclear diagnosis, and when exploratory laparotomy indications, laparotomy can be performed to confirm the diagnosis, and can be treated according to the intraoperative findings, laparotomy in the duodenum In the diagnosis and treatment of injuries, it has important diagnostic and therapeutic effects.

The preoperative clinical manifestations of duodenal injury are atypical, and misdiagnosis and missed diagnosis are prone to occur. In the laparotomy, missed diagnosis can also occur. Pi Zhimin and others have encountered 2 patients with duodenal injury, 1 of whom were outside the hospital. When the laparotomy was performed, the peritoneal exploration was not opened, so the diagnosis of duodenal injury was missed. In another case of extrauterine surgery, although the duodenum was explored, only the injury of the anterior wall was repaired, and the rupture of the posterior wall was omitted. Two patients were transferred to the Second Xiangya Hospital of Central South University. The diagnosis was confirmed by re-surgical laparotomy, so the following conditions were found during the exploration, and duodenal injury should be considered:

1 There is bile staining or fat necrosis or sputum pronunciation after retroperitoneal.

2 transverse mesenteric root, colonic hepatic flexion, hematoma after duodenum.

3 retroperitoneal hematoma with bile duct and pancreatic duct injury.

4 intraoperative pancreatic duct angiography, found pancreatic duct injury, especially with intra-pancreatic bile duct injury.

5 with right kidney, liver, inferior vena cava injury, it is necessary to point out that all parts of the duodenum should be examined in detail during surgery, such as: incision of the duodenal side peritoneal exploration descending and pancreatic head. Free colonic hepatic flexure and transverse mesenteric examination of the transverse section. Or the transverse part and the ascending part were examined by the avascular part of the right side of the transverse mesenteric root. Free ligaments of the ligaments, etc., any signs of suspicious damage found in the exploration, such as clots or hematomas on the intestinal wall, should be checked clearly, and minor injuries and multiple organ injuries should not be missed.

3. Judgment of the degree of duodenal injury

Severe or complicated duodenal injury means:

1 Duodenal descending injury rupture circumference > 75%, adjacent or has injured the nipple, duodenal blood supply loss.

2 The ball part, the horizontal part, and the rising part of the damage are 50% to 100%.

3 surgical treatment delay > 24h, tissue edema, inflammation is obvious.

4 combined with abdominal organ injury: such as pancreatic injury, lower common bile duct injury, large blood vessel injury, kidney damage, combined with severe craniocerebral injury, etc., in addition to the implementation of colon, gallbladder, biliary tract, right kidney and other intra-abdominal visceral surgery Because the tumor often invades the duodenum, it is easy to damage the duodenum when the tumor is removed. If it is found immediately, it can be treated reasonably for the injury. If it is not found during the operation, it may have serious consequences. Pei Minmin collected a number of cases of surgery for various organ malignancies in the abdomen. 42 cases were found to have invaded the duodenum, and 25 of them had primary tumors and invaded duodenal tumors. In the radical surgery for resection, 13 patients underwent palliative resection of primary cancer, and only the primary cancer was removed from the duodenal wall and removed (due to poor patient condition, the above surgery could not be performed), 4 cases In the removal of the primary tumor, the duodenum was inadvertently damaged. Among them, 3 cases were found to have bile contamination in the duodenal rupture operation. Therefore, the corresponding treatment measures were taken immediately, and good results were obtained, but another 1 The department was unable to detect and close the abdomen immediately after surgery. After the second day after surgery, the patient's condition deteriorated and was transferred to the Second Xiangya Hospital of Central South University. After laparotomy, the duodenum was found to be ruptured and perforated at the site of tumor invasion. Duodenum-jejunum Roux-Y lateral anastomosis after lesion removal.

Duodenal injury can be missed whether it is surgically explored or preoperatively. The preoperative missed diagnosis has been reported as high as 60% to 80%, which should be paid special attention by clinicians.

Differential diagnosis

It should be differentiated from the perforation caused by duodenal ulcer.

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