What is the optimal management of traumatic duodenal hematoma?

Management of Traumatic Duodenal Hematoma

The optimal management of traumatic duodenal hematoma is observation (d) for hemodynamically stable patients without other abdominal injuries requiring surgery.

Assessment and Classification

Traumatic duodenal hematomas are classified according to the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS):

• WSES class I-II / AAST-OIS grade I-II: Duodenal wall hematomas
• More severe grades involve full-thickness lacerations or complete transections

Management Algorithm

Initial Assessment

1. Evaluate hemodynamic stability (critical decision point)
2. Assess for signs of peritonitis or bowel evisceration
3. Perform CT scan to determine injury grade and associated injuries

Management Pathway

For Hemodynamically Stable Patients with Isolated Duodenal Hematoma:

• Non-operative management (NOM) is the treatment of choice 1
• Components of NOM:
  • Serial abdominal examinations
  • Bowel rest
  • Nasogastric tube decompression
  • Parenteral nutrition if obstruction persists beyond 7 days
  • Close monitoring with repeat imaging as needed

For Hemodynamically Unstable Patients OR Those with Peritonitis:

• Immediate operative intervention 1
• Damage control techniques should be considered in unstable patients

Evidence Supporting Non-operative Management

• NOM of duodenal hematomas is generally successful in both adults and children 1
• Failed NOM rates between 5-10.3% have been reported 1
• Patients managed non-operatively have reduced complication rates (0-3%) and reduced mortality compared to immediate operative management 1
• In a study of 74 patients with indirect signs of duodenal injury, only 5% of those initially managed non-operatively eventually required duodenal repair 2

When to Consider Operative Management

• Hemodynamic instability
• Peritonitis or bowel evisceration
• Progressive symptoms or worsening findings on repeat imaging 1
• Duodenal obstruction that has not resolved within 14 days of conservative management 1

Operative Options When Needed

If operative management becomes necessary:

• Evacuation of hematoma can be performed open or laparoscopically 1, 3
• Percutaneous drainage is a viable alternative 1

Outcomes

• Patients with isolated duodenal hematomas who are treated conservatively typically have shorter hospital stays (mean 6 days) compared to those treated surgically (mean 17 days) 4
• Non-operative management in appropriately selected patients is reasonable with close observation 2

Special Considerations

• Duodenal hematomas may be associated with acute pancreatitis, which can also be managed conservatively in most cases 5
• In patients with multiple intra-abdominal injuries, the duodenal hematoma may resolve spontaneously even when other injuries require surgical intervention 4
• Resection may be preferable to primary repair for higher-grade injuries (grade 3) if operative management is required 6

The evidence strongly supports observation as the optimal management strategy for traumatic duodenal hematomas in hemodynamically stable patients, with surgical intervention reserved for specific indications such as failure to resolve after 14 days or clinical deterioration.