European Journal of Radiology, 15 ( 1992) 163- 165 0

1992 Elsevier Science Publishers


B.V. All rights reserved. 0720-048X/92/$05.00

EURRAD 00288

Computed tomography of retroperitoneal duodenal rupture in blunt abdominal trauma M. Motateanu”, ‘Department

D. Mirescu a, A.-F. Schwieger”,

C. Laverribe b

of Radiology, bDepartment of Surgery, Hdpital Cantonal, University of Geneva, Geneva, Switzerland

(Received 16 December 1991; accepted after revision 17 February 1992)

Key words: Trauma, radiography; Trauma, abdomen; Abdomen, CT; Computed tomography, abdomen; Computed tomography, trauma


Two cases of retroperitoneal duodenum rupture following an upper abdominal blunt trauma are reported. Computed tomography (CT) demonstrates at best extraintestinal fluid and air in the retroperitoneum, especially if acquisition in right lateral decubitus is possible. Drawbacks of the method are also reviewed.

Introduction Duodenal retroperitoneal perforation is a rare but life-threatening complication arising in abdominal blunt trauma. If realizable, CT remains the most rapid and reliable diagnostic examination, disclosing retroperitoneal free air as well as intestinal fluid leakage and allowing a prompt surgical repair. These CT signs are well known, but often subtle and nonspecific. Case reports Case 1: a girl of 16 was kicked by a horse in the epigastric area. Laboratory data were normal and the clinical examination revealed local tenderness. Retroperitoneal free extraluminal air, shown as right paravertebral grapelike bubbles, was depicted on the abdominal plain films and confirmed by oral and intravenous contrast enhanced CT (Fig. la). Extravasation of the ingested contrast was documented in the right pararenal anterior space, particularly on images perCorrespondence

to: Mihail Motateanu, Division de Radiodiagnostic, HBpital Cantonal Universitaire de Geneve, 24 rue Micheli-du-Crest, CH - 12 11 Geneve 4 Switzerland.

formed in the right decubitus lateral position (Fig. lb). An emergency laparotomy four hours after the trauma revealed an isolated rupture of the second part of the duodenum, concerning two thirds of its circumference, without biliary leakage, which was primary sutured. Upper gastrointestinal series 10 days later showed no residual duodenal tear or fistula; the clinical course was satisfactory. Case 2: an 18-year-old male motorcycle rider was victim of a multisystem trauma, including upper abdominal contusion. An initial CT showed only a moderate quantity of intraperitoneal fluid. Development of peritonitis motivated a second CT examination. A small amount of diluted water-soluble contrast was introduced through a nasogastric tube in the sedated non-cooperative patient. Pneumoretroperitoneum, fluid in the right anterior pararenal and perirenal spaces, as well as a pneumoperitoneum, were demonstrated (Fig. 2). No extraintestinal contrast was confidently determined, but the clinical situation did not permit lateral decubitus CT imaging. An emergency laparotomy was performed 30 hours after the trauma, allowing the suture of a small duodenal laceration. The clinical course was then satisfactory.


Fig. l(a) Case 1, oral and intravenous contrast enhanced CT at the inferior renal pole level disclosing free air (large arrows) in the right anterior pararenal space. A mural hematoma is suspected in the second part of the duodenum (small arrows). Intraluminal oral contrast is visible beyond the ligament of Treitz (arrowhead). (b) Same patient as in a. Right lateral decubitus CT acquisition slice revealing oral contrast leakage from the second part of the duodenum (arrow) and a free retroperitoneal air bubble (arrowhead).


Fig. 2. Case 2, same enhancement technique as in Fig. 1. Fluid is visible in the right anterior pararenal (small black arrow) and in the perirenal (arrowheads) spaces. There are discrete retroperitoneal free air bubbles (large black arrows). Oral contrast is also visible in the distal small bowel (curved arrow). Pneumoperitoneum (white arrow) is secondary to air eruption from the retroperitoneum.

Duodenal injury is a rare complication of blunt upper abdominal trauma in adult (4-5 %) and pediatric (1%) When it occurs, mural hematoma, populations [l-3]. laceration or complete transsection of the duodenum are usually encountered, attributable to the following mechanisms: 1; tearing during deceleration, 2; crushing between the abdominal wall and the spine and 3; blowout [3]. Most duodenal injuries concern the second and third parts of the duodenum, which are retroperitoneal. Then, duodenal perforation can lead to a retroperitoneal leakage of intestinal fluid and air, with intraperitoneal extension if the trauma is sufficiently severe [4,5]. This complication can be clinically passive for 48 hours. The symptoms are non specific and consist of epigastric, flank or back pain with bilious vomiting [ 31. Laboratory data are usually normal. Delayed or missed diagnosis is associated with 65 % of mortality after 24 hours, due especially to septic shock [6], in contrast to 5 yO if operated earlier [7]. Proper surgical management depends on a quick diagnosis, which remains a radiological challenge. In hemodynamically stable patients CT, using intra-


venous and oral contrast, is the examination of choice enabling to reveal a traumatic retroperitoneal duodenal perforation. The CT signs are subtle and should be carefully searched with an appropriate window setting: intestinal fluid leakage and small bubbles of free air in the vicinity of the duodenum, as well as impairment of oral contrast progress towards the jejunum [2,4,8,9]. Mural duodenal hematoma is also well depicted either by CT [lo] or by ultrasound (US) [ 111. Finally, a complete view of other potentially injured organs is possible. The radiologist should be aware of some false positive CT results: (a) free retroperitoneal air can be secondary to a traumatic pneumothorax [ 1,121 and (b) extraluminal duodenal fluid can also be simulated by an extraperitoneal ruptured urinary bladder, as there are physiologic communications between the anterior and posterior pararenal spaces [ 121. Even if CT is very sensitive and false negative cases have, to our knowledge, not been reported, a normal CT examination should not disregard a retroperitoneal duodenal breach when this diagnosis is strongly suspected clinically. Introduction and improvement of the CT technique has supplanted the initial abdominal plain film and upper gastrointestinal series. The former, even if properly performed, is insufficient as it depicts up to only 33 y0 of cases of retroperitoneal free air [ 131. One author reported six surgically proved duodenal perforations, without evidence of pneumoretroperitoneum, by this technique [ 141. Contrast leakage delineates the duodenal breach in upper gastrointestinal series, but some authors have noted false negative examinations, with transient or sealed lacerations [ 1,4]. In addition, this organ specific procedure could be unrealizable in severely injured patients. In both cases reported here, CT diagnosed the retroperitoneal traumatic duodenal rupture and enabled a surgical repair with an acceptable delay. In the first case, we moreover performed additional slices in the right lateral decubitus, giving more chance for the oral contrast to escape from the intestinal lumen. In the literature, this position is usually recommended to enhance the duodenal opacification when a intraluminal or mural pathology is suspected, preventing the contrast to pool in the stomach [ 121. The clinical situation does not always allow such positioning. No arrest in the progress of the oral contrast was

noted in our two cases, probably due to an insufficient stricture of the intestinal lumen by the duodenal hematoma. In conclusion, when a retroperitoneal duodenal rupture is suspected, emergency abdominal CT with oral and intravenous contrast is the most reliable diagnostic procedure. It is easy to perform, very sensitive and not organ specific. Duodenal leakage could be better demonstrated if right lateral decubitus additional CT slices are feasible. Furthermore abdominal radiological studies are usually unnecessary and possibly associated injuries can be diagnosed during the same examination. The above-mentioned false positive situations need to be kept in mind, necessitating a complete review of the CT study before assessing the retroperitoneal duodenal rupture.

References 1 Bulas DI, Taylor GA, Eichelberger MR. The value of CT in detecting bowel perforation in children after blunt abdominal trauma. AJR 1989; 153: 561-564. 2 Hofer GA, Cohen AJ. CT signs of duodenal perforation secondary to blunt abdominal trauma. J Comput Assist Tomogr 1989; 13: 430-432. 3 Morton JR, Jordan JL Jr. Traumatic duodenal injuries. Review of 131 cases. J Trauma 1968; 8: 127-137. 4 Glazer GM, Buy JN, Moss AA, Goldberg HI, Federle MP. CT detection of duodenal perforation. AJR 1981; 137: 333-336. 5 Jeffrey RB, Federle MP, Wall S. Value of computed tomography in detecting occult gastrointestinal perforation. J Comput Assist Tomogr 1983; 7: 825-827. 6 Corley RD, Norcross WJ, Shoemaker WC. Traumatic injuries to the duodenum. Ann Surg 1985; 181: 92-98. 7 Roman E, Silva Y, Lucas C. Management of blunt duodenal injury. Surg Gynecol Obstet 1971; 132: 7-14. 8 Karnaze GC, Sheedy PF II, Stephens DH, McLeod RA. Computed tomography in duodenal rupture due to blunt abdominal trauma. J Comput Assist Tomogr 1981; 5: 267-269. 9 Li DKB, Burhenne HJ. Computed tomography of the stomach and duodenum: a review. Am J Gastroenterol 1983; 78: 36-41. 10 Plojoux 0, Hauser H, Wettstein P. Computed tomography of intramural hematoma of the small intestine. Radiology 1982; 144: 559-561. 11 Hayashi K, Futagawa S, Kozaki S, and al. Ultrasound and CT demonstration of intramural duodenal hematoma. Pediatr Radio1 1988; 18: 167. 12 Cook DE, Walsh JW, Vick CW, Brewer WH. Upper abdominal trauma: pitfalls in CT diagnosis. Radiology 1986; 159: 65-69. 13 Toxopeus MD, Lucas CE, Krabbenhoft KL. Roentgenographic diagnosis in blunt retroperitoneal duodenal rupture. Am J Roentgenol Radium Ther Nucl Med 1972; 115: 281-288. 14 Kelly G, Norton L, Moore G, Eiseman B. The continuing challenge of duodenal injuries. J Trauma 1978; 18: 160-164.

Computed tomography of retroperitoneal duodenal rupture in blunt abdominal trauma.

Two cases of retroperitoneal duodenum rupture following an upper abdominal blunt trauma are reported. Computed tomography (CT) demonstrates at best ex...
1MB Sizes 0 Downloads 0 Views