Duodenal Hematoma

Pediatric Duodenal HematomaAbdominal trauma in children should garner an appropriate amount of respect and concern. The child’s abdominal wall, unfortunately, is not as protective of the internal structures compared to adults’ abdominal wall. Additionally, signs of trauma can be minimal or nonexistent. Sometimes, the history alone is enough to raise a red flag. One of those history features is the classic bike injury sustained when the bike handlebar strikes the upper abdomen. Let’s digest a quick (and delicious) morsel on Duodenal Hematoma in Children:

 

Duodenal Hematoma: Anatomy Matters

  • Anatomic features that make children more susceptible to blunt abdominal trauma:
    • Less protective covering.
      • Thinner abdominal muscles and less fat.
    • Less protective ribs.
      • The compliant ribs do not dissipate force.
      • That transmitted force now is absorbed by the underlying organs and structures.
    • More exposed solid organs.
      • The diaphragm is more horizontal compared to older patients.
      • The liver and spleen are, thus, more anterior and less protected by rib cage.
  • All abdominal organs are at risk for injury. (Maguire, 2013)
    • Solid Organs
      • Liver injury is the most commonly seen in hospitalized patients (64%).
        • Abuse is reported as being the 2nd or 3rd most common cause of hepatic injury in children, after MVCs.
      • Kidney (19% of hospitalizations)
    • Hollow Organs (12% of hospitalizations)
      • Duodenal hematoma, perforation, and transection have been documented.
      • Often present in delayed fashion: 
        • Both accidental trauma non-accidental trauma can lead to DELAYED presentations.
        • May take more than 24 hours to manifest its severity. [Alkan, 2012; Clendenon, 2004]

 

Duodenal Hematoma: Basics

  • The duodenum is relatively protected given its retroperitoneal location.
    • Injuries to the duodenum are uncommon. [Sowrey, 2013]
    • <1% of traumas involved the pediatric duodenum. [Clendenon, 2004]
    • Unfortunately, historic data shows high mortality rates for those with duodenal injuries, although more recent data has lower mortality rates. [Clendenon, 2004]
    • Close proximity to other structures increases chance of concomitant injuries. [Sowrey, 2013]
  • Duodenal injuries: Adults vs Children
    • Adults injure their duodenum via penetrating trauma most often.
    • Children most often experience duodenal injuries via blunt trauma.
      • Unfortunately, this blunt force is often encountered through abuse. [Clendenon, 2004]
  • Difficult to diagnose:
    • Retroperitoneal location makes imaging less reliable.
      • Plain xrays will not show free air from duodenal perforations.
      • CT scans may show only subtle findings. [Kurkchubasche, 1997]
    • May lack external signs of trauma.
    • Delayed presentations make appreciation difficult.
      • Initial assessment following abdominal injury may under-represent the true injury.
      • Requires high index of suspicion.
  • Duodenal hematoma can lead to a partial or complete bowel obstruction.

 

Duodenal Hematoma: Mechanisms

  • Common blunt mechanism:
    • ABUSE
      • Numerous reports of duodenal injuries being related to non-accidental trauma. [Sowrey, 2013; Terreros, 2009; Gaines, 2004]
      • For younger children (< 5 years of age) abuse is the MOST COMMON mechanism of duodenal injury.[Sowrey, 2013]
      • Abuse should be suspected in all cases of duodenal injury in children < 2 years of age unless due to a witnessed motor vehicle collision. [Sowrey, 2013]
    • Bicycle handlebars [Alkan, 2012]
      • Handlebars can lead to penetrating or blunt trauma.
    • Hockey sticks
    • Motor Vehicle Collisions and All-Terrain Vehicle crashes
    • Fall onto object or object crushing down onto abdomen
    • Sports-related impacts
    • Invasive procedures [Sahn, 2015]
  • Crushing mechanism:
    • Mechanism is similar to the lap-belt complex injuries, but higher location on the abdomen.
    • Duodenum is crushed between the vertebral column and the handlebar.

 

Moral of the Morsel

  • Bikes are fun… but their handlebars can be painful! Don’t overlook the history of blunt trauma to a child’s abdomen, even if the exam is not revealing.
  • Be vigilant, but reasonable. Don’t CT ever child with a mild blunt force to the belly. GIVE GOOD ANTICIPATORY GUIDANCE and document that conversation.
  • Be suspicious of injuries in the young! If you find a duodenal (or any) injury in a young child, consider non-accidental injury.

 

References

Sahn B1, Anupindi SA, Dadhania NJ, Kelsen JR, Nance ML, Mamula P. Duodenal hematoma following EGD: comparison with blunt abdominal trauma-induced duodenal hematoma. J Pediatr Gastroenterol Nutr. 2015 Jan;60(1):69-74. PMID: 25207477. [PubMed] [Read by QxMD]

Sowrey L1, Lawson KA, Garcia-Filion P, Notrica D, Tuggle D, Eubanks JW 3rd, Maxson RT, Recicar J, Megison SM, Garcia NM. Duodenal injuries in the very young: child abuse? J Trauma Acute Care Surg. 2013 Jan;74(1):136-41; discussion 141-2. PMID: 23271088. [PubMed] [Read by QxMD]

Maguire SA1, Upadhyaya M, Evans A, Mann MK, Haroon MM, Tempest V, Lumb RC, Kemp AM. A systematic review of abusive visceral injuries in childhood–their range and recognition. Child Abuse Negl. 2013 Jul;37(7):430-45. PMID: 23306146. [PubMed] [Read by QxMD]

Alkan M1, Iskit SH, Soyupak S, Tuncer R, Okur H, Keskin E, Zorludemir U. Severe abdominal trauma involving bicycle handlebars in children. Pediatr Emerg Care. 2012 Apr;28(4):357-60. PMID: 19680164. [PubMed] [Read by QxMD]

Terreros A1, Zimmerman S. Duodenal hematoma from a fall down the stairs. J Trauma Nurs. 2009 Jul-Sep;16(3):166-8. PMID: 19888022. [PubMed] [Read by QxMD]

Gaines BA1, Shultz BS, Morrison K, Ford HR. Duodenal injuries in children: beware of child abuse. J Pediatr Surg. 2004 Apr;39(4):600-2. PMID: 15065036. [PubMed] [Read by QxMD]

Clendenon JN1, Meyers RL, Nance ML, Scaife ER. Management of duodenal injuries in children. J Pediatr Surg. 2004 Jun;39(6):964-8. PMID: 15185235. [PubMed] [Read by QxMD]

Plancq MC1, Villamizar J, Ricard J, Canarelli JP. Management of pancreatic and duodenal injuries in pediatric patients. Pediatr Surg Int. 2000;16(1-2):35-9. PMID: 10663831. [PubMed] [Read by QxMD]

Kurkchubasche AG1, Fendya DG, Tracy TF Jr, Silen ML, Weber TR. Blunt intestinal injury in children. Diagnostic and therapeutic considerations. Arch Surg. 1997 Jun;132(6):652-7; discussion 657-8. PMID: 9197859. [PubMed] [Read by QxMD]

Winthrop AL, Wesson DE, Filler RM. Traumatic duodenal hematoma in the pediatric patient. J Pediatr Surg. 1986 Sep;21(9):757-60. PMID: 3772698. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Health_Kenya says:

    Can it be treated conservatively.

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