How would duodenal stump insufficiency (DSI) be detected?

From the Guidelines

Duodenal stump insufficiency (DSI) would be detected through a combination of clinical assessment, laboratory findings, and diagnostic imaging, with contrast-enhanced CT-scan being the most comprehensive technique for evaluating duodeno-pancreatic injuries 1.

Clinical Presentation

Patients with DSI typically present with abdominal pain, fever, tachycardia, and signs of peritonitis within 1-7 days after surgery. Laboratory findings often show leukocytosis, elevated C-reactive protein, and sometimes elevated amylase levels in drainage fluid.

Diagnostic Imaging

The definitive diagnosis is made through imaging studies, with CT scan with oral contrast being the gold standard. The contrast will demonstrate leakage from the duodenal stump into the peritoneal cavity. Other diagnostic methods include:

• Fluoroscopy with water-soluble contrast
• Ultrasound to detect intra-abdominal fluid collections
• Analysis of drain output for elevated amylase and biliary content

Importance of Early Detection

Early detection is crucial as duodenal stump insufficiency carries high morbidity and mortality rates. The condition occurs when there is breakdown of the duodenal closure following partial gastrectomy with Billroth II reconstruction or total gastrectomy, allowing digestive enzymes and bile to leak into the peritoneal cavity, potentially causing severe peritonitis, sepsis, and multiorgan failure if not promptly identified and treated. Contrast-enhanced CT-scan has a sensitivity and specificity of 86% and 88%, respectively, in diagnosing blunt hollow viscus injury 1. However, careful CT-scan interpretation with clinical correlation is mandatory to avoid delayed diagnosis and treatment with increased morbidity and mortality 1.

From the Research

Detection of Duodenal Stump Insufficiency (DSI)

• Duodenal stump insufficiency is typically detected through a combination of clinical presentation and imaging studies 2, 3, 4, 5, 6
• Clinical signs of DSI may include abdominal pain, fever, and leakage of duodenal contents into the abdominal cavity 3, 4, 5, 6
• Imaging studies such as CT scans and ultrasound may be used to confirm the diagnosis of DSI and to guide treatment 2, 5, 6

Risk Factors for DSI

• Several risk factors have been identified for the development of DSI, including:
  • Presence of duodenal ulcer 3
  • Intra-operative contamination 3
  • Lower pre-operative hemoglobin levels 3
  • Duodenostomy 3, 4, 5
  • Penetrating duodenal ulcer disease 5

Treatment and Management of DSI

• Treatment of DSI typically involves a conservative approach with adequate drainage, nutrition, and antibiotics 3, 6
• Percutaneous interventions such as percutaneous drainage and percutaneous transcholecystic biliary diversion may also be used to manage DSI 2, 6
• Surgical approaches such as duodenojejunostomy and pancreatoduodenectomy may be reserved for severe cases or when conservative approaches fail 5, 6