Imaging Spectrum of Duodenal Emergencies

CT assessment of complications from gastric or duodenal ulcers

Gastric and duodenal ulcers (GDUs) are decreasing both in frequency and rate of mortality. However, GDUs with complications continue to have higher mortality rates and are seldom suspected in patients presenting with acute abdomen. Although upper endoscopy plays a central role in the diagnosis and treatment of GDUs, CT is crucial when serious complications appear, namely uncontrolled acute haemorrhage, perforation, organ penetration, or gastric obstruction. Radiologists have a special role to play in these situations, providing the diagnosis and extent of complications, thus contributing to decision making which can range from conservative management to endoscopic, surgical or interventional radiology procedures. The aim of our study is to describe the CT indications and protocols for patients with a suspected GDU with complications and present the main imaging findings for the different types of complications, while providing differential diagnoses.

A pictorial essay on cross-sectional imaging findings of pathologies in the second (D2) segment of the duodenum in adults

The duodenum, the initial segment of the small intestine, is divided into four parts: the superior (D1), descending (second) (D2), horizontal (D3), and ascending (D4) segments. Despite its short length, the descending part (D2 segment) holds clinical significance due to its anatomical proximity to structures such as the gallbladder, right kidney, colon, and pancreas. This anatomical localization and contiguity give rise to various pathologies, including congenital, inflammatory, infectious, neoplastic, vascular, and traumatic conditions. Cross-sectional imaging modalities play a pivotal role in evaluating pathologies of the second (D2) segment of the duodenum. This article aims to provide a comprehensive overview of these pathologies and delineate their imaging characteristics.

A case of small intestinal fixation failure

A 77-year-old woman underwent CT to evaluate haematemesis. The images showed that the third part of the duodenum flexed steeply on the right side of the aorta and ran caudally, without crossing anterior to the aorta. The duodenal-jejunal junction and jejunum were located on the patient's right side. Upper gastrointestinal endoscopy revealed a laceration at the gastric cardia, and a diagnosis of Mallory-Weiss syndrome was made. Repeat CT 7 days later revealed that the abnormal positioning of the intestinal tract had resolved spontaneously. Two months later, the patient experienced another episode of haematemesis, and CT revealed repeat deviation of the duodenal-jejunal junction and jejunum to her right side. Upper gastrointestinal endoscopy revealed another laceration at the gastric cardia, as in the previous study. On the basis of the initial CT findings showing the duodenal-jejunal junction in the right hemi-abdomen, intestinal malrotation was suspected. However, because the jejunum deviated repeatedly to the right side but resolved spontaneously, we diagnosed dysplasia of the ligament of Treitz. Laparotomy revealed a formed ligament of Treitz; however, fixation in the upper jejunum was incomplete. Additionally, CT revealed that the anterior pararenal space was loosely fixed and mobile. These factors may have caused the right-sided deviation of the small intestine. In this case, the third part of the duodenum likely flexed on the right side of the aorta, causing an obstruction that resulted in repeat vomiting episodes and Mallory-Weiss syndrome.

Case report emphasize pearls of duodenal perforation

INTRODUCTION

Isolated duodenal perforation secondary to trauma is a rare abdominal surgical condition, with a questionable surgical approach depending on the case.

PRESENTATION OF CASE

This is a case report of a 27-year-old male patient who presented with a free perforation in the posterior wall of the third portion of the duodenal frame and secondary retropneumoperitoneum without injuring any contiguous organ, after a medium-impact blunt abdominal trauma during a soccer game.

DISCUSSION

A laparotomy was performed, followed by duodenorraphy with Connell-Mayo suture and Lambert suture using vascular prolene in two planes. A nasogastric tube was placed up to the jejunum, and a Jackson-Pratt drain was placed in close to the duodenum next to the sutures. During hospitalization was found a positive bacterial culture of the peritoneal fluid hence received antibiotics, without complication.

CONCLUSION

It is essential to make a timely diagnosis with its respective individualized surgical approach and it must be managed as an emergency surgical procedure.

Imaging spectrum of non-neoplastic and neoplastic conditions of the duodenum: a pictorial review

Given its crucial location at the crossroads of the gastrointestinal tract, the hepatobiliary system and the splanchnic vessels, the duodenum can be affected by a wide spectrum of abnormalities. Computed tomography and magnetic resonance imaging, in conjunction with endoscopy, are often performed to evaluate these conditions, and several duodenal pathologies can be identified on fluoroscopic studies. Since many conditions affecting this organ are asymptomatic, the role of imaging cannot be overemphasized. In this article we will review the imaging features of many conditions affecting the duodenum, focusing on cross-sectional imaging studies, including congenital malformations, such as annular pancreas and intestinal malrotation; vascular pathologies, such as superior mesenteric artery syndrome; inflammatory and infectious conditions; trauma; neoplasms and iatrogenic complications. Because of the complexity of the duodenum, familiarity with the duodenal anatomy and physiology as well as the imaging features of the plethora of conditions affecting this organ is crucial to differentiate those conditions that could be managed medically from the ones that require intervention.

Surgical management of duodenal injury: experience from 92 cases

PURPOSE

Duodenal injury increases with traffic accidents, and delayed diagnosis or inappropriate operation increase mortality and complications. This study aimed to explore early recognition and timely surgical intervention.

METHODS

All patients with duodenal injuries treated operatively during the past 10 years were reviewed, and the data were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome.

RESULTS

A total of 92 patients with duodenal injuries accounted for 7.3% of 1258 patients with abdominal injury. Of the 92 patients, 71 (77.17%) experienced blunt trauma, with traffic accidents accounting for 59.2% (42/71). In 35 patients, a preoperative diagnosis was obtained by reviewing abdominal signs, peritoneocentesis, and imaging. The remaining 57 patients underwent urgent laparotomy, through which a definitive diagnosis of duodenal injury was confirmed during the operation. In all 92 patients, the surgical procedures involved simple sutures; pedicled jejunal piece coverings; and various anastomoses following resection of the injured duodenal portion, including the Whipple procedure and damage-control surgery principles. The overall mortality rate was 12.0% (11/92) with deaths mainly occurring due to associated injuries. When excluding 2 cases of intraoperative death, there were 47 cases in the double-tube gastrostomy group and 43 cases in the traditional triple-tube group, with mortality rates of 10.64% and 9.30% in the two groups, respectively (χ2 = 0.045, P > 0.05). Postoperative complications occurred in 15 patients (18.5%). There was a high incidence of duodenal (or pancreatic/biliary) leakage.

CONCLUSION

Early diagnosis and operation of duodenal injury are crucial to reducing complications and mortality. Surgical methods should be based on injury grade, associated injuries, and vital signs. Double-tube gastrostomy can reduce complications such as intestinal obstruction.

Radiologic Imaging of Traumatic Bowel and Mesenteric Injuries: A Comprehensive Up-to-Date Review

Diagnosing bowel and mesenteric trauma poses a significant challenge to radiologists. Although these injuries are relatively rare, immediate laparotomy may be indicated when they occur. Delayed diagnosis and treatment are associated with increased morbidity and mortality; therefore, timely and accurate management is essential. Additionally, employing strategies to differentiate between major injuries requiring surgical intervention and minor injuries considered manageable via non-operative management is important. Bowel and mesenteric injuries are among the most frequently overlooked injuries on trauma abdominal computed tomography (CT), with up to 40% of confirmed surgical bowel and mesenteric injuries not reported prior to operative treatment. This high percentage of falsely negative preoperative diagnoses may be due to several factors, including the relative rarity of these injuries, subtle and non-specific appearances on CT, and limited awareness of the injuries among radiologists. To improve the awareness and diagnosis of bowel and mesenteric injuries, this article provides an overview of the injuries most often encountered, imaging evaluation, CT appearances, and diagnostic pearls and pitfalls. Enhanced diagnostic imaging awareness will improve the preoperative diagnostic yield, which will save time, money, and lives.

A delayed presentation of a traumatic isolated duodenal injury

Blunt injury to the abdomen resulting in isolated duodenal injury is rare in surgical practice. Due to the insidious onset of symptoms and the vague non-specific nature of the clinical presentation, these injuries can be easily missed even in experienced hands. Contrary to Europe or developed countries, assaults to the abdomen using hands, fists, and feet in home-based violence is common in third-world countries. These patients have the habit of hiding the assault part of the history to avoid litigations to 'known' people. A high level of suspicion, a continuous revisiting of the history, and timely damage control surgery can improve the outcomes of such patients.

Review of Traumatic Duodenal Injuries: Etiology, Diagnosis, and Management

Traumatic duodenal injuries are rare and often challenging to diagnose and treat. Management of these injuries remains controversial and continues to evolve. Here, we performed a review of the literature and guidelines for the diagnosis and management of traumatic duodenal injuries.

A common recommendation in more recent literature is primary, tension-free repair of duodenal injuries when possible if surgical repair is necessary. Conversely, if duodenal injuries are unamenable to primary repair, more complex procedures such as Roux-en-Y duodenojejunostomy or pancreaticoduodenectomy may be necessary. Regardless of injury grade or type of surgical repair, the literature continues to support wide extraluminal drainage. Over time, the management of complex duodenal injuries has evolved to favor simple primary repair whenever possible. According to recent studies, more complex procedures are associated with higher rates of post-operative complications and should be reserved for severe injuries when primary repair is not possible.

The Role of Dual-Energy Computed Tomography in Locating Gastrointestinal Tract Perforations

Objective With each passing day, dual-energy computed tomography (DECT) is being used more frequently in the evaluation of abdominal pathologies. In this article, we aimed to assess the role of dual-energy CT in locating gastrointestinal perforations, which are among the causes of acute abdomen. Materials and methods All patients who underwent DECT due to acute abdomen in a COVID-19 designated hospital between June 1st, 2020 and December 31st, 2020, who were found to have gastrointestinal tract (GIT) perforation and underwent surgery were included in the study. DECT results and intraoperative findings of the patients were compared. Results Thirteen patients (nine males and four females) who underwent DECT for acute abdomen and were diagnosed with perforation in the gastrointestinal system were included in the study. The mean age of the patients was 57.6 years (range: 11-85 years). Two patients had gastric perforation, three had duodenal perforations, and one patient had a perforation in the gallbladder wall. Two patients were diagnosed with jejunal perforations, one patient with Meckel's diverticulum, and three patients with colorectal perforation. Although free air was detected in the abdomen of one patient, perforation could not be located. In patients with GIT perforation who were operated on following DECT imaging, the perforation location shown on DECT correlated 100% with the perforation locations detected during surgery. Conclusion DECT is significantly effective in planning surgical treatment and determining the foci of perforation in GIT perforations.