A 30-year-old man wearing a lap belt sustains a head-on collision. He has epigastric pain and repeated vomiting. Initial plain films are unremarkable. CT abdomen shows retroperitoneal free air and fluid collection around the second part of the duodenum. He is haemodynamically stable. The most appropriate management is:
- A Primary repair of the duodenal laceration with omental reinforcement ✓
- B Nasogastric drainage, broad-spectrum antibiotics and serial imaging
- C Pancreaticoduodenectomy
- D Pyloric exclusion with gastrojejunostomy as the first-line procedure
Explanation
Duodenal perforations are frequently missed initially because the second part is retroperitoneal and spillage is confined, giving normal early films. In a stable patient, most duodenal injuries are managed by simple debridement and primary transverse closure reinforced with an omentum, with wide drainage. Pyloric exclusion is reserved for large complex injuries or delayed presentations with dense inflammation, while pancreaticoduodenectomy is limited to massive destructive injuries involving the pancreatic head and ampulla. Nonoperative management of a full-thickness perforation risks fatal retroperitoneal sepsis.
Reference: Schwartz's Principles of Surgery, 11th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.