Because when the duodenum is injured, it doesn’t bleed, it waits.
The Quiet Saboteur
The duodenum sits there, tucked away behind the liver and stomach, doing its job quietly. Until one day, a handlebar, a steering wheel, a bullet, a knife, and it turns from bystander to assassin.
Duodenal trauma doesn’t announce itself. It leaks slowly, retroperitoneally, bathing the pancreas, bile duct, and vessels in digestive fluid while the patient looks deceptively well. By the time you realise what’s happening, the peritonitis has spread, and the clock is already ticking.
It’s not the bleeding that kills them.
It’s the delay.
Mechanism and Misery
Duodenal trauma comes in two flavours:
- Blunt, from compression against the spine (classic: handlebar or dashboard).
- Penetrating, usually from gunshots or stabs.
Blunt injuries shear or crush the duodenum, often splitting it across the second or third part, right where it wraps around the pancreatic head. Penetrating injuries? They rarely spare the neighbours.
You’re not managing a hole in a tube, you’re managing the intersection of bile, acid, pancreas, and blood.
If the liver is drama, the duodenum is intrigue.
The Anatomy That Betrays You
Four parts. Four different nightmares:
First part (D1):
- Intraperitoneal, it can behave.
- Injuries often visible and accessible, repair straightforward.
Second part (D2):
- The danger zone, retroperitoneal, hugging the pancreatic head, common bile duct, and portal vein.
- A hole here is never just a hole.
Third part (D3):
- Fixed, posterior, vulnerable to crush between aorta and vertebral column.
- Tears here are silent until infection erupts.
Fourth part (D4):
- Where the duodenum joins the jejunum.
- Deceleration and avulsion injuries are easy to miss.
If you can’t see the injury, it’s probably there.
The First Clue Is Often No Clue
Early diagnosis is rare. The classic signs, bile-stained NG aspirate, retroperitoneal air on imaging, rising amylase, are late guests to the party.
Mechanism and suspicion are your best diagnostic tools.
- Seatbelt mark over the upper abdomen?
Assume D2 or D3 injury. - Epigastric tenderness with minimal peritonism?
Think retroperitoneal leak. - Penetrating right upper quadrant wound crossing midline?
Explore. Don’t rationalise.
Imaging: The Great Revealer (Sometimes)
- CT with contrast is your ally, but not infallible.
Look for:- Retroperitoneal gas or fluid
- Contrast extravasation
- Thickened duodenal wall
- Adjacent pancreatic or biliary injury
- If unstable:
Forget the scanner. The only contrast you’ll see is blood on your gloves.
Surgical Exposure: The Hard Part Begins
A proper look at the duodenum requires commitment.
No shortcuts.
Step 1: Full Kocher manoeuvre:
Mobilise the duodenum and head of pancreas. Don’t stop halfway — you’ll miss the real injury.
Step 2: Cattell–Braasch if needed:
Medial visceral rotation to expose the infrarenal IVC, D3 and D4.
Step 3: Inspect pancreas, bile duct, and portal triad.
These injuries travel in packs.
Management Principles: Control, Drain, Divert
There’s no one-size-fits-all repair. The key is source control, stop the leak, drain the field, protect downstream flow.
Primary Repair (Simple and Honest)
For most partial-thickness or small lacerations (<50% circumference):
- Debride minimal devitalised tissue.
- Two-layer closure: inner absorbable full-thickness, outer seromuscular imbrication.
- Cover with omentum if possible.
- Wide closed-suction drains, always.
If it looks good and you can close without tension, do it. Don’t overthink.
Serosal or Contained Haematoma
- Observe if stable.
- If duodenal lumen compromised → decompress proximally with nasogastric tube or gastrostomy, and feed distally.
Major Injury, Duct Intact
If more than 50% circumference is destroyed but ampulla and duct are spared:
- Consider pyloric exclusion (temporarily closing the pylorus and draining the stomach via a gastrojejunostomy).
- Add feeding jejunostomy for early enteral nutrition.
This allows decompression and protection while the duodenum heals.
Combined Duodenal + Pancreatic Head Injury
Now you’re in trouble.
- Check ductal integrity (ERCP if time and stability allow).
- If pancreatic head destroyed or ampulla involved → staged management:
- Drain, decompress, damage control.
- Formal resection (Whipple) only when the patient’s physiology allows — rarely at the index operation.
Attempting definitive surgery on a cold, coagulopathic patient is a death sentence.
Ductal or Ampullary Involvement
This is the line between repair and reconstruction.
- If small and localised: repair over stent if possible.
- If extensive: Roux-en-Y duodenojejunostomy or tube duodenostomy with drainage.
- Always drain generously, retroperitoneal sepsis is unforgiving.
Adjuncts That Save Lives
- Feeding jejunostomy: early nutrition is life support for healing.
- Nasogastric decompression: keep the duodenum decompressed until healing proven.
- Drains: always, always drains.
If you think you don’t need one, you’re wrong.
When Damage Control Is the Only Option
When the patient’s pH is collapsing, the temperature is 34°C, and blood is running faster than you can transfuse it, don’t chase elegance.
- Pack, drain, decompress, and get out.
- Return in 24–48 hours once physiology is back from the brink.
You can’t heal mucosa in metabolic purgatory.
Complications: The Long Hangover
Even when you’ve done everything right:
- Duodenal fistula: persistent drainage, high output, skin corrosion.
- Retroperitoneal abscess: fever, tachycardia, that subtle “off” feeling days later.
- Sepsis and malnutrition: the slow killers.
- Stricture: the late reminder of a rushed repair.
Survival isn’t just making it off the table, it’s making it through the next fortnight.
The Mental Game
Duodenal trauma humbles you.
It hides until it’s too late, it leaks behind your back, and it punishes the overconfident.
You don’t master it, you survive it.
Every repair feels temporary. Every drain feels like insurance against regret.
And that’s the right mindset.
And From the Patient’s Side…
They’ll never know how close they came, how bile and acid nearly dissolved their survival from within, how the real fight wasn’t in the trauma bay, but in the quiet retroperitoneum where you battled time, anatomy, and entropy itself.
They’ll only know that they woke up, tubes everywhere, sore, bewildered, but alive.
Because you didn’t look away when the duodenum was hiding.
You turned over the pancreas, followed the track, and found the wound that would’ve killed them quietly.
And that’s why they’re still here.
