A 11-year-old girl is brought to the emergency department due to persistent vomiting. The first episode of emesis occurred 12 hours ago, and for the past 4 hours, the patient has been unable to keep any liquids down. She also has nausea and epigastric discomfort but no fever, abdominal distension, or diarrhea. The patient is a competitive gymnast. Yesterday, she fell and struck her abdomen hard on the balance beam during practice. Temperature is 36.7 C (98.1 F), blood pressure is 106/72 mm Hg, pulse is 110/min, and respirations are 18/min. On examination, mucous membranes are dry. Lung and heart sounds are normal. The abdomen is scaphoid with linear bruising across the epigastrium. On palpation, there is epigastric tenderness without guarding, rigidity, or rebound tenderness. Upright chest and abdominal x-rays are normal, with no free air under the diaphragm. Focused assessment with sonography for trauma reveals no intraperitoneal free fluid or air. Which of the following is the best next step in management of this patient?

Question

A 11-year-old girl is brought to the emergency department due to persistent vomiting.  The first episode of emesis occurred 12 hours ago, and for the past 4 hours, the patient has been unable to keep any liquids down.  She also has nausea and epigastric discomfort but no fever, abdominal distension, or diarrhea.  The patient is a competitive gymnast.  Yesterday, she fell and struck her abdomen hard on the balance beam during practice.  Temperature is 36.7 C (98.1 F), blood pressure is 106/72 mm Hg, pulse is 110/min, and respirations are 18/min.  On examination, mucous membranes are dry.  Lung and heart sounds are normal.  The abdomen is scaphoid with linear bruising across the epigastrium.  On palpation, there is epigastric tenderness without guarding, rigidity, or rebound tenderness.  Upright chest and abdominal x-rays are normal, with no free air under the diaphragm.  Focused assessment with sonography for trauma reveals no intraperitoneal free fluid or air.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient has epigastric discomfort, nausea, and worsening emesis approximately 1 day after blunt abdominal trauma (BAT) (eg, balance beam impact). This presentation is concerning for duodenal hematoma (DH) and is best evaluated with abdominal CT scan. Rapid compression of the duodenum against the vertebral column during BAT can injure blood vessels between the submucosal and the muscularis layers, causing bleeding and hematoma formation. Continued hematoma expansion over the subsequent 24-48 hours can lead to progressive obstruction of the duodenal lumen, as in this patient with worsening emesis who can no longer tolerate liquids (eg, complete obstruction). CT scan of the abdomen can confirm the diagnosis and visualize the extent of the hematoma, which typically appears as a homogenous density (ie, coagulated blood) within the C-shaped duodenum. Once confirmed, DHs typically are managed with bowel rest, nasogastric decompression, and parenteral nutrition and are followed with serial CT scans or duodenal ultrasonography. Most DHs resolve within a few weeks with nonoperative management. homogenous density (Choice A) Although this patient should receive antiemetics, her abdominal pain and worsening emesis with an inability to tolerate fluids are concerning for intraabdominal injury following BAT and warrant further workup (eg, imaging). (Choice C) The role of diagnostic peritoneal lavage has been largely reduced to evaluating for intraabdominal hemorrhage in hemodynamically unstable patients with questionable bedside ultrasound results. This patient is hemodynamically stable and can undergo definitive imaging with CT scan. (Choice D) Exploratory laparotomy is indicated when patients with BAT have peritonitis (eg, rigidity, rebound tenderness) or hemodynamic instability (eg, systolic blood pressure <90 mm Hg) with evidence of intraabdominal hemorrhage (eg, intraperitoneal free fluid). This patient has none of these indications. Exploratory laparotomy (Choice E) Gallbladder ultrasonography is commonly used to evaluate for suspected cholecystitis, which can cause epigastric discomfort and emesis but typically also causes fever and right upper quadrant tenderness. Isolated gallbladder injury from BAT is extremely rare, given the gallbladder's protected location under the liver's edge. Educational objective: Rapid compression of the duodenum against the vertebral column during blunt abdominal trauma may result in a duodenal hematoma. Hematoma expansion can progressively obstruct the duodenal lumen, causing a delayed (24-48 hr) presentation of worsening emesis. CT scan confirms the diagnosis. References: Pancreatic and duodenal trauma in children. (http://www.ncbi.nlm.nih.gov/pubmed/31110846) Intramural duodenal hematoma: clinical course and imaging findings. (http://www.ncbi.nlm.nih.gov/pubmed/31007947)

A 11-Year-Old Girl Is Brought to the Emergency Department Due