A 22-year-old cyclist strikes his upper abdomen against handlebars. He presents six hours later with persistent epigastric pain and vomiting. Plain radiograph shows mottled lucency over the right retroperitoneum and loss of the right psoas shadow, with no free air under the diaphragm. CT with oral contrast shows extravasation of contrast into the retroperitoneum around the second part of the duodenum. The most appropriate management is:

• A Nasogastric decompression and total parenteral nutrition for expected spontaneous healing
• B Exploratory laparotomy with wide Kocherisation and primary repair of the duodenal laceration ✓
• C CT-guided retroperitoneal drain insertion
• D Endoscopic placement of a self-expanding covered stent across the defect

Explanation

Blunt rupture of the retroperitoneal second part of the duodenum is a classic handlebar injury. Because the leak is retroperitoneal, free air under the diaphragm is usually absent and diagnosis is often delayed; retroperitoneal contrast extravasation on CT confirms a full-thickness perforation, which mandates operative repair. After Kocherisation the laceration is closed primarily with drainage and gastric decompression. Nonoperative management is safe only for intramural haematoma without perforation, and stenting is not established therapy for acute blunt duodenal rupture.

Reference: Sabiston Textbook of Surgery, 21st ed.

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