DIAGNOSIS AND MANAGEMENT OF DUODENAL INJURIES IN CHILDREN

Traumatic duodenal perforations in children pose a diagnostic and ther apeutic challenge. To identify specific diagnostic criteria and define an optimal therapeutic protocol, we reviewed all duodenal injuries tr eated at our institution in the past 10 years. There were 14 hematomas and 13 perforations, The diagnosis was confirmed by computed tomograp hy (CT), ultrasound scan (US), upper gastrointestinal contrast studies (UGI), or at laparotomy. The clinical findings and CT findings of the two groups were compared, Children with suspected duodenal hematomas were treated expectantly, and children with duodenal perforations were treated surgically, Twenty-five associated injuries(10 pancreatic) oc curred in 19 children, Children with perforations had higher injury se verity scores (ISS) (25 v 9), but the two groups could not be differen tiated based on presenting signs, symptoms, or laboratory findings. CT findings of retroperitoneal air or contrast were seen in 9 of 9 perfo rations and in 0 of 10 hematomas. CT findings of intraabdominal or ret roperitoneal fluid, mesenteric enhancement, and thickened duodenal wal l did not differentiate the two groups. Duodenojejunostomy was perform ed in one patient, and primary repair was performed in 11 children who had perforation, In five children, duodenostomy tube drainage with fe eding jejunostomy or gastrojejunostomy were added. Complications occur red in three of four children in the first 5 years of the study and in two of nine children in the last 5 years. The decreased morbidity rat e correlated with reduced time to definitive therapy (28 v 7.8 hours), Duodenal fistulae resulted in three of seven children treated without duodenostomy tube drainage and zero of five treated with drainage. En teral feeds resumed faster (average, 12 v 27 days) if repair of perfor ation was combined with feeding jejunostomy or pyloric exclusion and g astrojejunostomy. Children with duodenal hematoma resumed eating an av erage of 16 days after injury. Only one child required surgery for per sistent obstruction. The findings of retroperitoneal air and contrast extravasation on CT accurately distinguish duodenal perforation from h ematoma. Conservative management of hematoma is safe and effective. Pr imary repair of perforation with duodenal drainage results in fewer po stoperative complications, and gastrojejunostomy or feeding jejunostom y shorten the time to resumption of feeds. Copyright (C) 1997 by W. B. Saunders Company.