[D4 duodenal injury: a case report and literature review]

Duodenal injury in blunt abdominal trauma is a rare and often requires complex repair. We present a case of duodenal injury successfully managed with primary repair and jejunostomy. Additionally, we reviewed the literature devoted to the management of duodenal injuries, particularly D4 duodenal injuries. A 34-year-old male patient came to the emergency department with severe abdominal pain caused by a workplace accident. The patient's condition on arrival was stable. Abdominal examination: severe epigastric pain, bruising and skin scratches in epigastric area, positive signs of abdominal rigidity, and inaudible peristaltic movements. Computed Tomography (CT) of the abdomen revealed free air in abdominal cavity and retroperitoneal space. The patient underwent emergency surgery 4 hours after the accident. Intraoperatively, we found rupture of the fourth part of duodenum and stomach. These injuries were chosen for primary repair combined with jejunostomy. The patient recovered after surgery, and there were no complications. Rupture of D4 duodenum can result from falling and hitting the back on a hard surface, while gastric rupture may occur due to direct impact on abdominal wall. Free retroperitoneal air adjacent to D4 segment is indicative of duodenal injury. Extensive suturing of surrounding tissues and two-layer suture repair at the injury site are necessary. Additionally, jejunostomy was imposed to prevent complications such as duodenal leaks. Due to anatomical characteristics of D4, primary repair can be effective for duodenal injuries up to grade III. Extensive abdominal drainage and jejunostomy are essential for fast recovery and minimal risk of complications related to duodenal leaks.