- Email: [email protected]
Management of traumatic duodenal hematomas in children
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Management of traumatic duodenal hematomas in children Michelle L. Peterson, MS, Paulette I. Abbas, MD, Sara C. Fallon, MD, Bindi J. Naik-Mathuria, MD, and Jose Ruben Rodriguez, MD* Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
article info
abstract
Article history:
Background: Duodenal hematomas from blunt abdominal trauma are uncommon in
Received 3 January 2015
children and treatment strategies vary. We reviewed our experience with this injury at a
Received in revised form
large-volume children’s hospital.
1 April 2015
Materials and methods: A retrospective case series was assembled from January 2003eJuly
Accepted 2 April 2015
2014. Data collected included demographics, clinical and radiographic characteristics, and
Available online xxx
hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II
Keywords:
injuries.
Duodenal hematoma
Results: Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7e17.2 y).
Blunt abdominal trauma
Mechanisms of injury included direct abdominal blow or handle bar injury (n ¼ 9),
Pediatric surgery
nonaccidental trauma (n ¼ 5), falls (n ¼ 3), and motor vehicle accident (n ¼ 2). Ten patients
Pediatric trauma
had grade I hematomas and nine had grade II. Hematomas were most frequently seen in
Nonoperative management
the second portion of the duodenum (n ¼ 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5e14 d). Median duration of PN for grade I was 6.5 d (range, 5e8 d) versus 12 d for grade II (range, 9e14 d; P ¼ 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest. Conclusions: This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Duodenal hematomas secondary to blunt abdominal trauma are rare in the pediatric population. Because of its retroperitoneal location, the duodenum is often protected, and therefore, injury of the duodenum occurs in only 3%e5% of all
patients with trauma-related abdominal injuries [1]. The majority (>70%) of pediatric duodenal hematomas result from blunt abdominal trauma, which differs from the adult population where penetrating trauma is a more common mechanism [1,2]. The anatomy of a child increases the risk of duodenal injury from blunt trauma because of decreased
* Corresponding author. Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030. Tel.: þ1 832 822 3135; fax: þ1 832 822 3141. E-mail address: [email protected] (J.R. Rodriguez). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.04.015
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e4
intraabdominal fat and less protection from the costal margin, which is more horizontal [3]. Treatment has traditionally been nonoperative, thus avoiding laparotomy and its associated morbidity. Therapy includes bowel rest and nasogastric decompression, peripherally inserted central catheter (PICC) placement, and parenteral nutrition (PN) [1,2,4,5]. Duration can vary substantially, and enteral nutrition is resumed when gastric aspirates are no longer bilious. There are few published studies examining this management approach in children. This limits the trauma surgeon’s ability to counsel patients and families on the expected hospital course, need for PN, and complication profiles. The purpose of this study was to review this rare injury in children treated at a level 1 trauma center to better characterize the outcomes of this patient population.
2.
Methods
2.1.
Patient characteristics
After receiving approval from the institutional review board (H-31028), a retrospective chart review was conducted including patients treated from January 2003eJuly 2014 with duodenal injuries after blunt abdominal trauma at a level 1 children’s hospital. The institutional trauma registry, which prospectively maintains data on trauma admissions, was used to identify our study population. This patient list was cross-referenced to a query of the hospital records by International Classification of Diseases, 9th Revision (ICD-9) code for duodenal injury. Children with duodenal perforations or deserosalization injuries without an associated duodenal hematoma were excluded.
2.2.
Study design
Data collection included demographics, presentation and injury details, clinical and radiographic characteristics, hospital course, and complications. Resolution of the hematoma was defined as return of bowel function with the ability to tolerate an oral diet. Radiographic resolution was also documented, if available. When considering complications, pancreatitis was defined in this study as a discharge diagnosis of pancreatitis after having persistent symptoms and prolonged elevation of amylase. This diagnosis was then confirmed by evaluating the progress notes and laboratory results for the patients. The American Association for the Surgery of Trauma (AAST) Duodenum Injury Scale was used to classify the grade of injury [6]. According to the AAST guidelines, a grade I injury is a hematoma involving a single portion of the duodenum; grade II injury involves more than one portion. Patients were stratified by their AAST injury score and further analyzed.
2.3.
Statistical analysis
Statistical analyses performed included the Student t-test for continuous variables or the chi-square test for categorical variables. A P value of <0.05 was considered statistically significant. Data are presented as median with range.
3.
Results
During the 11.5-y study period, 835 patients were identified with blunt trauma to the foregut and 27 patients were found to have a duodenal injury. Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7e17.2 y); 32% were female. The remaining eight patients had duodenal perforations or deserosalization injuries distinct from a duodenal hematoma. None of these patients were identified as having a duodenal hematoma before the perforation or deserosalization injury. The most common mechanism of injury was a direct abdominal blow, which included sports injury (n ¼ 4), handlebar injury (n ¼ 3), one patient who was struck in the abdomen by another individual, and one patient who was stepped on by a horse. Other mechanisms included nonaccidental trauma (n ¼ 5), falls (n ¼ 3), and motor vehicle accident (n ¼ 2). The most common symptoms at presentation were abdominal pain (n ¼ 17) and nausea or vomiting (n ¼ 9) with a median duration of 1.25 d (range, 0.13e7 d) before admission to the Emergency Department. Patients were evaluated with our institution’s blunt abdominal trauma laboratory panel. On admission, the median international normalized ratio (n ¼ 9) was 1.2 (range, 1.1e1.7). The median lipase (n ¼ 18) was 760 (range, 21e6714), and was elevated in 11 of 18 patients. Similarly, the median amylase (n ¼ 18) was 120 (range, 32e3395), with 10 of 18 patients with an elevated level. The diagnostic test of choice was a computed tomography (CT) scan, and all patients were scanned either on admission to our Emergency Department (n ¼ 14) or at an outside hospital before transfer (n ¼ 7); two patients were rescanned at our facility because of missing or poor quality imaging. Duodenal hematomas were most frequently noted in the second portion of the duodenum (n ¼ 9). Nine patients had associated abdominal injuries, which included grade I pancreatic injury (n ¼ 3), grade II pancreatic injury (n ¼ 1), grade I liver injury (n ¼ 1), grade II liver injury (n ¼ 1), small bowel perforation (n ¼ 2), small bowel hematoma (n ¼ 1), and mesenteric injury (n ¼ 2). The five patients with non-accidental trauma had additional nonabdominal injuries typical of child abuse, such as a hip fracture, bruising and contusions, scalp hematomas, intracranial hemorrhage, and one patient with a pneumothorax. Three of the five patients had concomitant abdominal injuries. Five patients underwent an emergent laparotomy for concerns of hollow viscous injury. During each operation, the duodenal hematoma was noted but left intact. No patients ultimately required operative drainage of the hematoma. Twelve patients (63%) received PN for a median of 9 d (range, 5e14 d), which includes all but one of the operative patients (who expired within 2 d of admission secondary to traumatic brain injury). Although no patient required surgical decompression, one patient received percutaneous drainage of the hematoma 2 d after admission. The decision to drain the hematoma was at the discretion of the surgeon and was due to the large size with signs of obstruction. Additionally, the size of the hematoma (6 cm fluid collection) and its accessibility through a retroperitoneal approach made the percutaneous drainage procedure feasible. Moreover, further diagnostic information
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e4
was obtained when aspiration failed to show enteric contents. Percutaneous access into the left upper quadrant was obtained through a lateral subcostal approach. A 10.2F multipurpose catheter was placed, and approximately 30 cc of old blood was drained. The drain remained in place for 3 d until output decreased to a minimal amount. His nasogastric tube was removed 2 d later, and his diet was advanced. He was discharged 3 d after the drain was removed for a total hospital stay of 8 d. Although all patients had clinical resolution of their hematoma over a median time of 7.69 d (range, 2e44.2 d), imaging studies (ultrasound, CT, and upper gastrointestinal [GI] series) were performed to follow hematomas in six of the 18 surviving patients (33%). Complete resolution on imaging was documented in three patients. Decreasing size of hematomas was confirmed by imaging in three patients (two CT scans and one upper GI series). Complications from their abdominal trauma included sepsis (n ¼ 1) and readmission for partial small bowel obstruction managed nonoperatively (n ¼ 1). The readmitted patient presented with abdominal pain and vomiting. CT imaging revealed a residual duodenal hematoma without evidence of bowel obstruction, and an upper GI series showed no evidence of gastric outlet obstruction or perforation. He was managed with bowel rest and his partial obstruction resolved in 3 d. The patient who developed sepsis had a positive blood culture result (Staphylococcus hominis) from a PICC line culture. The patient was placed on vancomycin and transitioned to clindamycin after culture sensitivity results returned. A blood culture drawn 7 d after the initial positive result was negative. Patients were stratified based on initial CT scans into either grade I or grade II hematomas according to the AAST Duodenum Injury Scale. Ten patients were found to have a grade I hematoma (53%); nine patients had grade II hematoma (47%). When patient demographics and outcomes between grade I and grade II injuries were compared, there were no significant differences between the two groups except for duration of PN (Table 1).
Table 1 e Characteristics and outcomes of patients based on grade of injury. Characteristics and outcomes Age, median (range), y ISS score, median (range) Average size of hematoma SD, cm Duration of PN, median (range), d Use of nasogastric tube, n (%) Duration of NG tube, median (range), d Time to oral intake, median (range), d Length of stay, median (range), d
Grade I (N ¼ 10)
Grade II (N ¼ 9)
P value
9.6 (1.7e14.9) 4 (4e41) 3.2 1.9
6.9 (3e17.2) 4.5 (4e34) 5.0 5.7
0.315 0.968 0.386
6.5 (5e8)
12 (9e14)
0.016
7 (70)
6 (67)
0.876
6.5 (5e21)
6.5 (0e12)
0.662
7 (0e23)
10.1 (2e41)
0.686
8 (1e26)
16 (2e54)
0.156
SD ¼ standard deviation; ISS ¼ injury severity score; NG ¼ nasogastric tube.
4.
3
Discussion
Duodenal hematomas are rarely encountered in blunt pediatric trauma. [1,2,4,7e9] Because of its location, an isolated duodenal hematoma is infrequently encountered and typically other abdominal organ injuries are identified as well [1,5,7]. They are usually incidentally diagnosed when the mechanism of injury or the physical examination leads to a high suspicion of other hollow viscus injury, and the patient receives a CT scan for evaluation. In this study, we found that the grade of duodenal injury helps to predict the duration of a patient’s hospital course. A grade II hematoma was associated with longer duration of PN therapy and subsequently longer hospital stay. Although the length of stay was not statistically different, the differences may have clinical implications, as the length of stay was two times longer for patients with grade II hematomas. Our data support the need for early PICC line placement and initiation of PN in patients with a grade II duodenal injury when compared with a grade I injury. Our center’s success with nonoperative management is consistent with other institutional reports [1,2,4,5,8e10]. In our study, only one patient required a procedural intervention related to the hematoma, and the patient had successful return of bowel function. Successful utilization of percutaneous drainage has been described in other studies with similar outcomes [11e13]. In this particular case, the surgeon was concerned with the large size and suspicion for contained duodenal perforation. Therefore, the drainage procedure was both diagnostic and therapeutic. In a study reported by Iuchtman et al., two of nine patients needed surgical drainage when no improvement was noticed after 14e16 d from admission, which was not required in the current patient population [2]. Although the resolution of the hematoma in our series was based on clinical symptomatology with marginal use of radiographic confirmation, there are reports of using imaging to document improvement in the duodenal obstruction [8]. Although both follow-up strategies have their advantages, we only had one readmission related to an incompletely resolved hematoma, which argues against routine imaging in every patient. Clinical parameters, such as nasogastric tube output, appear to be effective in determining hematoma resolution with ultrasound reserved for refractory cases. Although there is a possibility that duodenal hematomas could be missed due to increasing reticence to CT scan pediatric trauma patients, it should be used in the appropriate clinical setting. The increasing role for the utility of sonographic evaluation as a screening test warrants consideration, but with specific clinical indications, cross-sectional imaging continues to be the standard of care. The increasing availability of magnetic resonance imaging is another alternative, but it is not regularly used for trauma at this time. There were no deaths related to the duodenal injury, and subsequent morbidity was the result of concomitant injuries with the exception of line sepsis. This low morbidity parallels the results previously described by Shilyansky et al. [9] in which only two of 14 patients developed complications including a fibrous stricture at the site of a hematoma
4
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e4
requiring surgical revision and one who developed an infected pseudocyst requiring drainage. There have also been reports of wound infections and small bowel obstruction in the postoperative period, which we did not encounter in our series [2,5]. The conclusions of our study are limited by its retrospective nature and the small sample size of our population. A strong argument could be made for a multicenter contribution of data and prospective data collection to more accurately determine clinical criteria for hematoma resolution. Our study describes successful nonoperative management of duodenal hematomas in pediatric patients. It also begins to define differences in outcomes of these hematomas based on duodenal injury score. Although the injury score has been described in other studies evaluating duodenal injuries, ours is the first study to use this score to specifically evaluate outcomes in patients with duodenal hematomas, exclusive of higher grades of duodenal injury [1,14].
5.
Conclusion
Isolated duodenal hematomas do not mandate surgery and are likely to resolve with bowel rest and nutritional support. Duodenal hematomas secondary to blunt abdominal traumas can be safely managed nonoperatively in children, although other abdominal injuries may require operative intervention. Higher grade of duodenal injury, as defined by the AAST guideline, is related to longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning for surgeons and parental counseling in children who present with this rare finding.
Acknowledgment Authors’ contributions: M.L.P., P.I.A., S.C.F., and J.R.R. conceptualized and designed the study; acquired, analyzed, and interpreted the data presented; drafted the initial article, reviewed, and edited the article; and approved the final article as submitted. B.J.N-M. reviewed and revised the article for intellectual content and approved the final article as submitted.
Disclosure The authors have no disclosures of funding or financial support to disclose with regard to the preparation of this article. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[1] Clendenon JN, Meyers RL, Nance ML, Scaife ER. Management of duodenal injuries in children. J Pediatr Surg 2004;39:964. [2] Iuchtman M, Steiner T, Faierman T, Breitgand A, Bartal G. Post-traumatic intramural duodenal hematoma in children. Isr Med Assoc J 2006;8:95. [3] Terreros A, Zimmerman S. Duodenal hematoma from a fall down the stairs. J Trauma Nurs 2009;16:166. [4] Torba M, Gjata A, Buci S, Troci A, Subashi K. Delayed presentation of blunt duodenal injuries in children. Case report and review of literature. G Chir 2013;34:122. [5] Desai KM, Dorward IG, Minkes RK, Dillon PA. Blunt duodenal injuries in children. J Trauma 2003;54:640. discussion 645e6. [6] Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990;30:1427. [7] Bhattacharjee HK, Misra MC, Kumar S, Bansal VK. Duodenal perforation following blunt abdominal trauma. J Emerg Trauma Shock 2011;4:514. [8] Yeung VH, Chao NS, Leung MW, Kwok WK. An unusual cause of intestinal obstruction in an adolescent: a case report and management review. Pediatr Rep 2009;1:e8. [9] Shilyansky J, Pearl RH, Kreller M, Sena LM, Babyn PS. Diagnosis and management of duodenal injuries in children. J Pediatr Surg 1997;32:880. [10] Touloukian RJ. Protocol for the nonoperative treatment of obstructing intramural duodenal hematoma during childhood. Am J Surg 1983;145:330. [11] Patterson VM, Goettler CE, Thomas CC. Traumatic duodenal hematoma in a pediatric patient treated by percutaneous drainage. Am Surg 2011;77:E220. [12] Moon SB, Jung SE, Cheon JE, Kim WS, Park KW. Very large traumatic duodenal hematoma: successful percutaneous drainage in a child. Eur J Pediatr Surg 2009;19:412. [13] Yang JC, Rivard DC, Morello FP, Ostlie DJ. Successful percutaneous drainage of duodenal hematoma after blunt trauma. J Pediatr Surg 2008;43:e13. [14] Bozkurt B, Ozdemir BA, Kocer B, Unal B, Dolapci M, Cengiz O. Operative approach in traumatic injuries of the duodenum. Acta Chir Belg 2006;106:405.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Management of traumatic duodenal hematomas in children Michelle L. Peterson, MS, Paulette I. Abbas, MD, Sara C. Fallon, MD, Bindi J. Naik-Mathuria, MD, and Jose Ruben Rodriguez, MD* Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
article info
abstract
Article history:
Background: Duodenal hematomas from blunt abdominal trauma are uncommon in
Received 3 January 2015
children and treatment strategies vary. We reviewed our experience with this injury at a
Received in revised form
large-volume children’s hospital.
1 April 2015
Materials and methods: A retrospective case series was assembled from January 2003eJuly
Accepted 2 April 2015
2014. Data collected included demographics, clinical and radiographic characteristics, and
Available online xxx
hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II
Keywords:
injuries.
Duodenal hematoma
Results: Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7e17.2 y).
Blunt abdominal trauma
Mechanisms of injury included direct abdominal blow or handle bar injury (n ¼ 9),
Pediatric surgery
nonaccidental trauma (n ¼ 5), falls (n ¼ 3), and motor vehicle accident (n ¼ 2). Ten patients
Pediatric trauma
had grade I hematomas and nine had grade II. Hematomas were most frequently seen in
Nonoperative management
the second portion of the duodenum (n ¼ 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5e14 d). Median duration of PN for grade I was 6.5 d (range, 5e8 d) versus 12 d for grade II (range, 9e14 d; P ¼ 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest. Conclusions: This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Duodenal hematomas secondary to blunt abdominal trauma are rare in the pediatric population. Because of its retroperitoneal location, the duodenum is often protected, and therefore, injury of the duodenum occurs in only 3%e5% of all
patients with trauma-related abdominal injuries [1]. The majority (>70%) of pediatric duodenal hematomas result from blunt abdominal trauma, which differs from the adult population where penetrating trauma is a more common mechanism [1,2]. The anatomy of a child increases the risk of duodenal injury from blunt trauma because of decreased
* Corresponding author. Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1210, Houston, TX 77030. Tel.: þ1 832 822 3135; fax: þ1 832 822 3141. E-mail address: [email protected] (J.R. Rodriguez). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.04.015
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e4
intraabdominal fat and less protection from the costal margin, which is more horizontal [3]. Treatment has traditionally been nonoperative, thus avoiding laparotomy and its associated morbidity. Therapy includes bowel rest and nasogastric decompression, peripherally inserted central catheter (PICC) placement, and parenteral nutrition (PN) [1,2,4,5]. Duration can vary substantially, and enteral nutrition is resumed when gastric aspirates are no longer bilious. There are few published studies examining this management approach in children. This limits the trauma surgeon’s ability to counsel patients and families on the expected hospital course, need for PN, and complication profiles. The purpose of this study was to review this rare injury in children treated at a level 1 trauma center to better characterize the outcomes of this patient population.
2.
Methods
2.1.
Patient characteristics
After receiving approval from the institutional review board (H-31028), a retrospective chart review was conducted including patients treated from January 2003eJuly 2014 with duodenal injuries after blunt abdominal trauma at a level 1 children’s hospital. The institutional trauma registry, which prospectively maintains data on trauma admissions, was used to identify our study population. This patient list was cross-referenced to a query of the hospital records by International Classification of Diseases, 9th Revision (ICD-9) code for duodenal injury. Children with duodenal perforations or deserosalization injuries without an associated duodenal hematoma were excluded.
2.2.
Study design
Data collection included demographics, presentation and injury details, clinical and radiographic characteristics, hospital course, and complications. Resolution of the hematoma was defined as return of bowel function with the ability to tolerate an oral diet. Radiographic resolution was also documented, if available. When considering complications, pancreatitis was defined in this study as a discharge diagnosis of pancreatitis after having persistent symptoms and prolonged elevation of amylase. This diagnosis was then confirmed by evaluating the progress notes and laboratory results for the patients. The American Association for the Surgery of Trauma (AAST) Duodenum Injury Scale was used to classify the grade of injury [6]. According to the AAST guidelines, a grade I injury is a hematoma involving a single portion of the duodenum; grade II injury involves more than one portion. Patients were stratified by their AAST injury score and further analyzed.
2.3.
Statistical analysis
Statistical analyses performed included the Student t-test for continuous variables or the chi-square test for categorical variables. A P value of <0.05 was considered statistically significant. Data are presented as median with range.
3.
Results
During the 11.5-y study period, 835 patients were identified with blunt trauma to the foregut and 27 patients were found to have a duodenal injury. Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7e17.2 y); 32% were female. The remaining eight patients had duodenal perforations or deserosalization injuries distinct from a duodenal hematoma. None of these patients were identified as having a duodenal hematoma before the perforation or deserosalization injury. The most common mechanism of injury was a direct abdominal blow, which included sports injury (n ¼ 4), handlebar injury (n ¼ 3), one patient who was struck in the abdomen by another individual, and one patient who was stepped on by a horse. Other mechanisms included nonaccidental trauma (n ¼ 5), falls (n ¼ 3), and motor vehicle accident (n ¼ 2). The most common symptoms at presentation were abdominal pain (n ¼ 17) and nausea or vomiting (n ¼ 9) with a median duration of 1.25 d (range, 0.13e7 d) before admission to the Emergency Department. Patients were evaluated with our institution’s blunt abdominal trauma laboratory panel. On admission, the median international normalized ratio (n ¼ 9) was 1.2 (range, 1.1e1.7). The median lipase (n ¼ 18) was 760 (range, 21e6714), and was elevated in 11 of 18 patients. Similarly, the median amylase (n ¼ 18) was 120 (range, 32e3395), with 10 of 18 patients with an elevated level. The diagnostic test of choice was a computed tomography (CT) scan, and all patients were scanned either on admission to our Emergency Department (n ¼ 14) or at an outside hospital before transfer (n ¼ 7); two patients were rescanned at our facility because of missing or poor quality imaging. Duodenal hematomas were most frequently noted in the second portion of the duodenum (n ¼ 9). Nine patients had associated abdominal injuries, which included grade I pancreatic injury (n ¼ 3), grade II pancreatic injury (n ¼ 1), grade I liver injury (n ¼ 1), grade II liver injury (n ¼ 1), small bowel perforation (n ¼ 2), small bowel hematoma (n ¼ 1), and mesenteric injury (n ¼ 2). The five patients with non-accidental trauma had additional nonabdominal injuries typical of child abuse, such as a hip fracture, bruising and contusions, scalp hematomas, intracranial hemorrhage, and one patient with a pneumothorax. Three of the five patients had concomitant abdominal injuries. Five patients underwent an emergent laparotomy for concerns of hollow viscous injury. During each operation, the duodenal hematoma was noted but left intact. No patients ultimately required operative drainage of the hematoma. Twelve patients (63%) received PN for a median of 9 d (range, 5e14 d), which includes all but one of the operative patients (who expired within 2 d of admission secondary to traumatic brain injury). Although no patient required surgical decompression, one patient received percutaneous drainage of the hematoma 2 d after admission. The decision to drain the hematoma was at the discretion of the surgeon and was due to the large size with signs of obstruction. Additionally, the size of the hematoma (6 cm fluid collection) and its accessibility through a retroperitoneal approach made the percutaneous drainage procedure feasible. Moreover, further diagnostic information
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e4
was obtained when aspiration failed to show enteric contents. Percutaneous access into the left upper quadrant was obtained through a lateral subcostal approach. A 10.2F multipurpose catheter was placed, and approximately 30 cc of old blood was drained. The drain remained in place for 3 d until output decreased to a minimal amount. His nasogastric tube was removed 2 d later, and his diet was advanced. He was discharged 3 d after the drain was removed for a total hospital stay of 8 d. Although all patients had clinical resolution of their hematoma over a median time of 7.69 d (range, 2e44.2 d), imaging studies (ultrasound, CT, and upper gastrointestinal [GI] series) were performed to follow hematomas in six of the 18 surviving patients (33%). Complete resolution on imaging was documented in three patients. Decreasing size of hematomas was confirmed by imaging in three patients (two CT scans and one upper GI series). Complications from their abdominal trauma included sepsis (n ¼ 1) and readmission for partial small bowel obstruction managed nonoperatively (n ¼ 1). The readmitted patient presented with abdominal pain and vomiting. CT imaging revealed a residual duodenal hematoma without evidence of bowel obstruction, and an upper GI series showed no evidence of gastric outlet obstruction or perforation. He was managed with bowel rest and his partial obstruction resolved in 3 d. The patient who developed sepsis had a positive blood culture result (Staphylococcus hominis) from a PICC line culture. The patient was placed on vancomycin and transitioned to clindamycin after culture sensitivity results returned. A blood culture drawn 7 d after the initial positive result was negative. Patients were stratified based on initial CT scans into either grade I or grade II hematomas according to the AAST Duodenum Injury Scale. Ten patients were found to have a grade I hematoma (53%); nine patients had grade II hematoma (47%). When patient demographics and outcomes between grade I and grade II injuries were compared, there were no significant differences between the two groups except for duration of PN (Table 1).
Table 1 e Characteristics and outcomes of patients based on grade of injury. Characteristics and outcomes Age, median (range), y ISS score, median (range) Average size of hematoma SD, cm Duration of PN, median (range), d Use of nasogastric tube, n (%) Duration of NG tube, median (range), d Time to oral intake, median (range), d Length of stay, median (range), d
Grade I (N ¼ 10)
Grade II (N ¼ 9)
P value
9.6 (1.7e14.9) 4 (4e41) 3.2 1.9
6.9 (3e17.2) 4.5 (4e34) 5.0 5.7
0.315 0.968 0.386
6.5 (5e8)
12 (9e14)
0.016
7 (70)
6 (67)
0.876
6.5 (5e21)
6.5 (0e12)
0.662
7 (0e23)
10.1 (2e41)
0.686
8 (1e26)
16 (2e54)
0.156
SD ¼ standard deviation; ISS ¼ injury severity score; NG ¼ nasogastric tube.
4.
3
Discussion
Duodenal hematomas are rarely encountered in blunt pediatric trauma. [1,2,4,7e9] Because of its location, an isolated duodenal hematoma is infrequently encountered and typically other abdominal organ injuries are identified as well [1,5,7]. They are usually incidentally diagnosed when the mechanism of injury or the physical examination leads to a high suspicion of other hollow viscus injury, and the patient receives a CT scan for evaluation. In this study, we found that the grade of duodenal injury helps to predict the duration of a patient’s hospital course. A grade II hematoma was associated with longer duration of PN therapy and subsequently longer hospital stay. Although the length of stay was not statistically different, the differences may have clinical implications, as the length of stay was two times longer for patients with grade II hematomas. Our data support the need for early PICC line placement and initiation of PN in patients with a grade II duodenal injury when compared with a grade I injury. Our center’s success with nonoperative management is consistent with other institutional reports [1,2,4,5,8e10]. In our study, only one patient required a procedural intervention related to the hematoma, and the patient had successful return of bowel function. Successful utilization of percutaneous drainage has been described in other studies with similar outcomes [11e13]. In this particular case, the surgeon was concerned with the large size and suspicion for contained duodenal perforation. Therefore, the drainage procedure was both diagnostic and therapeutic. In a study reported by Iuchtman et al., two of nine patients needed surgical drainage when no improvement was noticed after 14e16 d from admission, which was not required in the current patient population [2]. Although the resolution of the hematoma in our series was based on clinical symptomatology with marginal use of radiographic confirmation, there are reports of using imaging to document improvement in the duodenal obstruction [8]. Although both follow-up strategies have their advantages, we only had one readmission related to an incompletely resolved hematoma, which argues against routine imaging in every patient. Clinical parameters, such as nasogastric tube output, appear to be effective in determining hematoma resolution with ultrasound reserved for refractory cases. Although there is a possibility that duodenal hematomas could be missed due to increasing reticence to CT scan pediatric trauma patients, it should be used in the appropriate clinical setting. The increasing role for the utility of sonographic evaluation as a screening test warrants consideration, but with specific clinical indications, cross-sectional imaging continues to be the standard of care. The increasing availability of magnetic resonance imaging is another alternative, but it is not regularly used for trauma at this time. There were no deaths related to the duodenal injury, and subsequent morbidity was the result of concomitant injuries with the exception of line sepsis. This low morbidity parallels the results previously described by Shilyansky et al. [9] in which only two of 14 patients developed complications including a fibrous stricture at the site of a hematoma
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requiring surgical revision and one who developed an infected pseudocyst requiring drainage. There have also been reports of wound infections and small bowel obstruction in the postoperative period, which we did not encounter in our series [2,5]. The conclusions of our study are limited by its retrospective nature and the small sample size of our population. A strong argument could be made for a multicenter contribution of data and prospective data collection to more accurately determine clinical criteria for hematoma resolution. Our study describes successful nonoperative management of duodenal hematomas in pediatric patients. It also begins to define differences in outcomes of these hematomas based on duodenal injury score. Although the injury score has been described in other studies evaluating duodenal injuries, ours is the first study to use this score to specifically evaluate outcomes in patients with duodenal hematomas, exclusive of higher grades of duodenal injury [1,14].
5.
Conclusion
Isolated duodenal hematomas do not mandate surgery and are likely to resolve with bowel rest and nutritional support. Duodenal hematomas secondary to blunt abdominal traumas can be safely managed nonoperatively in children, although other abdominal injuries may require operative intervention. Higher grade of duodenal injury, as defined by the AAST guideline, is related to longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning for surgeons and parental counseling in children who present with this rare finding.
Acknowledgment Authors’ contributions: M.L.P., P.I.A., S.C.F., and J.R.R. conceptualized and designed the study; acquired, analyzed, and interpreted the data presented; drafted the initial article, reviewed, and edited the article; and approved the final article as submitted. B.J.N-M. reviewed and revised the article for intellectual content and approved the final article as submitted.
Disclosure The authors have no disclosures of funding or financial support to disclose with regard to the preparation of this article. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
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