Isolated traumatic duodenal rupture due to bicycle handlebar injury in an adult patient

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1 Hong Kong Journal of Emergency Medicine Isolated traumatic duodenal rupture due to bicycle handlebar injury in an adult patient AY Wang, TH Lin, SC Chen Because of the well-developed abdominal musculature, the possibility of injury of the retroperitoneal organs such as the duodenum is not as high as that in children. Adult cases of isolated traumatic duodenal rupture caused by bicycle handlebar injury are extremely rare. We report a patient who experienced persistent abdominal pain after having a bicycle handlebar injury. Since the injury is hard to identify, abdominal computed tomography is performed to confirm the diagnosis. We also present a management flow chart to help physicians managing handlebar injuries in adults. (Hong Kong j.emerg.med. 2015;22: ) CT Keywords: Adult, blunt injury, computed tomography, small intestine injuries, traffic accident Introduction Although traumatic duodenal rupture due to bicycle handlebar injury is common in children, the condition is extremely rare in adults. Since adults have well developed abdominal musculature, the possibility of injury induced adverse effects on retroperitoneal organs is not as high as that in children. The duodenum is located in the retroperitoneal region, and it is hard to detect such injury initially if there is no associated major vascular or spinal injury. Here, we report a case of a young adult who developed isolated traumatic duodenal rupture due to bicycle handlebar injury. We also present a flowchart that would help clinicians on managing this condition. Correspondence to: Lin Tzu Hsin, MD National Taiwan University Hospital, Department of Traumatology, No. 7 Chung Shan South Road, Taipei 100, Taiwan jsl555@gmail.com National Taiwan University Hospital, Department of Emergency Medicine, No. 7 Chung Shan South Road, Taipei 100, Taiwan Wang An Yi, MD Chen Shyr Chyr, MD Case A 20-year-old healthy young woman fell from her bicycle and her abdomen hit against the handlebar while she was riding home from her night school at about 9 pm. She had no injuries on her extremities and showed no neurological deficit. She visited a nearby local hospital for an evaluation and was discharged

2 114 Hong Kong j. emerg. med. Vol. 22(2) Mar 2015 without further treatment after several plain abdominal X-rays were obtained. However, her abdominal pain worsened throughout the night. She was brought to our emergency department the following morning at 9 am. She did not have nausea or vomiting. On examination, she was conscious and her vital signs were stable (temperature: 37.1 o C, blood pressure: 104/67 mm Hg, heart rate: 88 beats/min, and respiratory rate: 16 breaths/min). A 4.5 cm ecchymosis consisting of a concentric circular pattern was detected over the right upper quadrant of her abdomen (Figure 1A). There was also obvious tenderness over the right upper abdomen without rebounding pain or radiation to other areas. Laboratory data showed leukocytosis (white blood cell count: 15.08x10 9 /L) without anaemia (haemoglobin l: 13.6 g/dl). Bedside ultrasonography showed no haemoperitoneum or pneumoperitoneum. Furthermore, chest radiography showed no subphrenic or intraabdominal free air. Further abdominal imaging was scheduled considering the injury mechanism and clinical symptoms. Contrast enhanced abdominal computed tomography (CT) was arranged and showed focal mucosal discontinuation at the third part of the duodenum; therefore, duodenal perforation was considered (Figure 1B, white arrows). The patient received an emergency exploratory laparotomy. A single perforation measuring 1.5 cm was noted at the third part of the duodenum (Figure 1C, black arrow) with mild bilious fluid leakage into the peritoneal cavity (Figure 1C, white arrowhead). Primary closure of the duodenal perforation site was performed and we also set a decompression duodenal tube. Jejunostomy was created for feeding. Her general condition improved gradually despite minor leaks from the closed wound vacuum drain (daily leakage of 5-10 ml of bilious content). After her general condition had stabilised, she attempted to take water orally on post-operative day (POD) 27. Thereafter, all drain tubes were removed. After smooth resumption of oral intake, she was discharged on POD 34 and followed up at surgical clinics. There was no residual abscess or duodenal leakage after 3 months of follow-up at our clinics. Discussion Traumatic duodenal rupture due to bicycle handlebar injury in paediatric patients has been well documented, 1 and other handlebar associated injuries such as abdominal wall hernia have been reported. 2 The high frequency of such injuries may be because of children's longer duration of riding a bicycle and relative under development of the abdominal wall. Adult cases of abdominal injury caused by bicycle handlebars are extremely rare, and our literature review showed that only one such case of traumatic small bowel bleeding has been reported thus far. 3 However, in particular, an adult case of isolated traumatic duodenal injury caused by bicycle handlebars has not yet been reported. Therefore, we report this case so that it serves as a reminder for first line physicians to consider such a duodenal injury when evaluating bicycle related injuries in adults. Traumatic duodenal injury is rare, with an incidence rate of 3-5%, 4 and can manifest as a penetrating or blunt injury. Penetrating duodenal injury is more common, accounting for 77.7% of all reported cases of traumatic duodenal injury, while blunt injuries account for the remaining 22.3%. 5 The diagnosis of penetrating duodenal injury is relatively straight forward. However, early diagnosis of blunt duodenal injury, especially isolated duodenal injury, is challenging. The major part of the duodenum is located in the retroperitoneal space, making physical examination difficult. Moreover, the symptoms can be subtle unless extravasation of intraluminal contents causes peritoneal irritation. In most cases, blunt injuries are caused by crushing of the duodenum between the seat belt or handlebar and the spine because of rapid acceleration and deceleration impacts over the anterior abdomen, as in the cases of motor vehicle or bicycle accidents. The retroperitoneal space is relatively difficult to approach by examination and injury to that area is easily overlooked unless severe, life threatening peritonitis develops or an associated injury such as Chance fracture or vascular injury is

3 Wang et al./duodenal rupture due to handlebar injury 115 noted. Early diagnosis of isolated duodenal injuries is important since a delay in surgery would increase the mortality rate. 6 Abdominal tenderness is observed in nearly 92% of blunt duodenal injuries, whereas abdominal wall ecchymosis or abrasion is observed in only 23%. Furthermore, previously reported laboratory data showed that elevated amylase levels was only present in 27% of blunt duodenal injury cases. 7 Bedside ultrasonography or Focused Assessment with Sonography for Trauma (FAST) is often used as the first step to detect the presence of free fluid in the abdomen. The reported sensitivity and specificity for the detection of intraperitoneal free air by an experienced physician was 93% and 64%, respectively. 8 However, it is difficult to detect free air localised to the retroperitoneal space by abdominal sonography. The sensitivity and specificity of FAST for detecting haemodynamically stable blunt trauma is 41% and 99%, respectively. 9 Delayed diagnosis or even misdiagnosis of a duodenal injury can be devastating; however, results of the physical and laboratory examination may be non-specific and those of the Figure 1. (A) An about 4.5 cm concentric-circle skin mark over right upper quadrant of abdomen. (B) Abdominal computed tomography scan with contrast enhancement showed focal mucosal discontinuation at third part of duodenum (white arrows), and fluid accumulation in Morrison pouch. (C) Below transverse colon and right lateral to spine, there is a 1.5 cm perforation hole (black arrow) noted in the third part of duodenum with mild bilious fluid leakage into the peritoneum. Several spots of haematoma (arrowheads) were noted in nearby retroperitoneal area and serosal surface of transverse colon.

4 116 Hong Kong j. emerg. med. Vol. 22(2) Mar 2015 FAST examination may be false negative. Therefore, further imaging studies may be needed. Radiographic studies provide a more detailed anatomical description of the retroperitoneal space. Furthermore, in cases of subtle duodenal injuries, contrast enhanced abdominal CT can provide crucial diagnostic information. Therefore, abdominal CT has been used to differentiate duodenal perforation from haematoma, since perforation may require an operation while haematoma without perforation can be managed conservatively. 10 Our patient was diagnosed with typical grade III duodenal perforation according to the American Association for the Surgery of Trauma guidelines. If diagnosed in time, in most cases, retroperitoneal duodenal perforation can be repaired by performing a simple surgical procedure. 11 The intervals between injury and diagnosis and injury and ATLS: Advanced Trauma Life Support, FAST: Focused Assessment with Sonography for Trauma, CT: computed tomography Figure 2. Management flow chart for handlebar abdominal trauma in adult.

5 Wang et al./duodenal rupture due to handlebar injury 117 operation are particularly important for reducing morbidity and mortality. If the interval between injury and diagnosis is more than 24 hours, the mortality rate increases to 29%. 12 Several studies conducted in major trauma centres have shown that hospitalisation and prolonged observation are not required in cases of stable blunt abdominal injuries. 13 It is also safe to discharge a paediatric patient after negative findings are obtained in CT studies. 13 Therefore, here, we also present a flow chart to help physicians manage handlebar injuries in adults (Figure 2). Identification of isolated blunt duodenal injury on first encounter continues to be a challenge for physicians. Through this case report, we would like to remind clinicians of the possibility of duodenal perforation due to the trauma mechanism resulting from impact of a bicycle handlebar on the abdomen. In such cases, the initial symptoms and signs are non-specific, and a detailed imaging study should be performed, even in adult cases, if a history of injury caused by bicycle handlebar impact is suspected. References 1. Winston FK, Weiss HB, Nance ML, Vivarelli-O Neill C, Stromeyer S, Lawrence BA, et al. Estimates of the incidence and costs associated with handlebar-related injuries in children. Arch Pediatr Adolesc Med 2002; 156(9): Ballard RB, Badellino MM, Eynon CA, Spott MA, Staz CF, Buckman RF Jr. Blunt duodenal rupture: a 6-year statewide experience. J Trauma 1997;43(2): Bohmer JH, Proust AF. Adult bicycle handlebar injury. Am J Emerg Med 2006;24(5): Carrillo EH, Richardson JD, Miller FB. Evolution in the management of duodenal injuries. J Trauma 1996; 40(6): Asensio JA, Feliciano DV, Britt LD, Kerstein MD. Management of duodenal injuries. Curr Probl Surg 1993;30(11): Levison MA, Petersen SR, Sheldon GF, Trunkey DD. Duodenal trauma: experience of a trauma center. J Trauma 1984;24(6): Chen SC, Wang HP, Chen WJ, Lin FY, Hsu CY, Chang KJ, et al. Selective use of ultrasonography for the detection of pneumoperitoneum. Acad Emerg Med 2002;9(6): Natarajan B, Gupta PK, Cemaj S, Sorensen M, Hatzoudis GI, Forse RA. FAST scan: is it worth doing in hemodynamically stable blunt trauma patients? Surgery 2010;148(4): Kunin JR, Korobkin M, Ellis JH, Francis IR, Kane NM, Siegel SE. Duodenal injuries caused by blunt abdominal trauma: value of CT in differentiating perforation from hematoma. AJR Am J Roentgenol 1993;160(6): Huerta S, Bui T, Porral D, Lush S, Cinat M. Predictors of morbidity and mortality in patients with traumatic duodenal injuries. Am Surg 2005;71(9): Lucas CE, Ledgerwood AM. Factors influencing outcome after blunt duodenal injury. J Trauma 1975; 15(10): Livingston DH, Lavery RF, Passannante MR, Skurnick JH, Fabian TC, Fry DE, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multiinstitutional trial. J Trauma 1998;44(2): Hom J. The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography. Acad Emerg Med 2010;17(5):

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