Gastric and Duodenal Injuries Overview

Penetrating Gastric Injuries

• Penetrating gastric injuries often cause a full-thickness perforation, leading to gastric content spillage into the abdomen.
• Peritonitis is a potential sign of gastric injury, which often develops faster than small bowel perforations due to the lower pH of gastric contents.
• The location and size of penetrating wounds can suggest a gastric injury.
• CT scans are commonly used to identify hollow visceral injuries in stable trauma patients before surgery.
• CT sensitivity and specificity for hollow visceral injuries is limited, ranging from 55% to 95% sensitivity and 48% to 92% specificity.
• CT findings include bowel wall thickening, irregular wall enhancement, mesenteric defects, and free fluid.
• Although free fluid is a common finding, it’s not a reliable indicator for surgery, with surgical intervention ranging from 27% to 54%.

Duodenal Injuries

• Duodenal injuries are relatively rare, making up less than 2% of abdominal trauma cases.
• Penetrating trauma is the most common cause, often involving gunshot or knife wounds.
• Duodenal injuries often occur alongside other injuries, impacting 70% of cases.
• High mortality is associated with arrival hemodynamics, transfusion needs, Injury Severity Score (ISS), renal failure, and pancreatic injury.
• Blunt duodenal injuries result from impacts to the epigastrium, leading to contusion or rupture of the duodenal wall due to increased intraluminal pressure.
• Diagnosing duodenal injuries can be challenging due to their retroperitoneal location.
• CT scans with a low threshold for operative exploration are crucial for diagnosis.
• Imaging findings include thickened duodenal walls, periduodenal air or fluid, and low-grade injuries like hematomas.
• For suspected duodenal trauma, repeat imaging studies like oral contrast-enhanced CT or upper GI fluoroscopy are recommended to monitor duodenal transit.
• Any evidence of perforation on imaging requires immediate surgery.

Management of Duodenal Injuries

• Management strategies depend on the injury's location and tissue destruction.
• Hematomas often resolve spontaneously without intervention, unless they're obstructing the gastric outlet.
• Obstructive hematomas are managed with gastric decompression, parenteral nutrition, and reevaluation of gastric emptying using a contrast study.
• If obstruction persists after 14 days, operative exploration is required to evacuate hematomas, evaluate for perforation/strictures, and assess associated pancreatic injuries.
• Primary repair is commonly performed in 98% of cases with operative duodenal injuries, including AAST grades.
• A single or double layer approach following debridement of devitalized tissues is frequently utilized.
• Complete mobilization of the duodenum with a Kocher maneuver facilitates repair.
• Larger tissue loss or transection may require resection and primary anastomosis.
• Longer segments or ampulla-adjacent injuries may necessitate enteric bypass (Roux-en-Y reconstruction).
• Protective maneuvers, such as omental placement over repairs, and techniques like pyloric exclusion/tube duodenostomy are sometimes employed.
• Drain placement decisions are individualized after repair.

Pancreatic Injuries

• Pancreatic injuries often occur alongside duodenal injuries due to their proximity.
• Temporary discontinuity during damage control can be effective in preventing contamination.

This quiz explores the characteristics and management of penetrating gastric and duodenal injuries. It highlights the significance of CT scans in diagnosing these injuries and discusses the clinical implications of the findings. Understanding these concepts is crucial for trauma care professionals.