Isolated duodenal perforation at D4 following blunt abdominal trauma

Isolated duodenal injuries are particularly rare in blunt abdominal trauma as the duodenum is at a deep and relatively well-protected anatomical site.

We present a case report of a 22-year-old male patient who presented to an accident and emergency department at a tertiary training hospital within four hours of sustaining blunt abdominal trauma. His vital signs were stable at this point and was found to have slight abdominal tenderness in the epigastric area with no abdominal rigidity and normal bowel sounds on auscultation. A CT Scan of the abdomen done was normal. He was admitted to the surgical ward for serial abdominal monitoring. Eight hours into his admission, his physical condition deteriorated necessitating an emergency laparotomy where a perforation of D4 on the anterior wall was found. This was repaired primarily and he had a relatively calm post-operative stay in the surgical ward and was discharged home.

Diagnosis of blunt duodenal injury is often delayed because of its retroperitoneal nature. Initial clinical changes in isolated duodenal injury may be extremely subtle before peritonitis sets in. It is therefore important to consider both mechanism of injury and other clinical signs such as tachycardia and raised white cell count as delays in diagnosis and subsequent management adversely affect morbidity and mortality.

Timely management of this rare and life threatening injury is hinged on a high index of suspicion in spite of what previous imaging may show to the surgeon.