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Protocol for the nonoperative treatment of obstructing intramural duodenal hematoma during childhood
Insights
Nonoperative management of obstructing intramural duodenal hematoma in children is effective. This approach, utilizing imaging and nutritional support, avoids surgery and leads to excellent outcomes.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Diagnostic Imaging
Background:
- Obstructing intramural duodenal hematoma (OIDH) in children often results from blunt abdominal trauma.
- Nonoperative management strategies are increasingly explored as alternatives to surgical intervention.
Purpose of the Study:
- To outline a prospective nonoperative treatment plan for OIDH.
- To evaluate the efficacy of diagnostic imaging and nutritional support in managing OIDH.
- To identify potential risk factors and associated injuries in pediatric OIDH cases.
Main Methods:
- Prospective development and application of a nonoperative management plan.
- Utilized contrast roentgenograms for diagnosis and monitoring hematoma evolution.
- Employed ultrasonography, serum amylase, and lipase for pancreatic injury assessment.
- Assessed the effectiveness of nasogastric suction and total parenteral nutrition.
Main Results:
- Eight of twelve pediatric patients achieved oral intake within the first week.
- Four patients required prolonged nasogastric suction and total parenteral nutrition (13-38 days).
- Residual duodenal deformity did not impede adequate oral nutrition post-treatment.
Conclusions:
- A nonoperative management plan for OIDH is a successful alternative to surgery.
- Sequential imaging and nutritional support are crucial for successful nonoperative treatment.
- Child abuse and underlying hematologic disorders should be considered in pediatric OIDH cases.
Abstract:
A prospective plan for the nonoperative treatment of obstructing intramural duodenal hematoma was developed to (1) promptly establish the diagnosis and rule out transmural leaks by obtaining a contrast roentgenogram on admission and to subsequently study evolution of the obstructing intramural duodenal hematoma with sequential roentgenograms at 5 to 7 day intervals; (2) identify associated pancreatic injury with ultrasonography and serum amylase and lipase determinations; and (3) to determine effectiveness of nasogastric suction and total parenteral nutrition. Twelve children, who ranged in age from 2 to 15 years, with obstructing intramural duodenal hematoma following blunt injury were admitted over the past 9 years. The two youngest were battered children and two others had subsequently diagnosed clotting disorders (idiopathic thrombocytopenic purpura and von Willebrand's disease). Significant resolution of the obstruction allowed resumption of oral intake by the end of the first week of treatment in eight patients, whereas the remaining four required 13, 14, 22, and 38 days of nasogastric suction and total parenteral nutrition. Residual deformity seen on roentgenograms did not interfere with achieving adequate oral nutrition. Excellent results in this series substantiate the conclusion that a management plan that assesses the evolution of an obstructing intramural duodenal hematoma and provides adequate nutrition is a successful alternative to surgical treatment. The presence of underlying hematologic disorders and child abuse must be suspected.