A 10-year-old boy is brought to the emergency department due to postprandial abdominal pain and bilious emesis. He has never had similar symptoms and has no other medical conditions. Two days ago, the patient stopped his bicycle abruptly and slammed into the handlebar. He immediately experienced abdominal pain, which improved over the next several hours. Vital signs are normal. Physical examination shows epigastric tenderness without rigidity or rebound tenderness. Bowel sounds are normal. Bedside ultrasonography reveals no intraperitoneal free fluid. Plain abdominal radiograph shows gastric dilation with scant distal gas. Laboratory results are as follows: Which of the following is the most likely diagnosis?

Question

A 10-year-old boy is brought to the emergency department due to postprandial abdominal pain and bilious emesis.  He has never had similar symptoms and has no other medical conditions.  Two days ago, the patient stopped his bicycle abruptly and slammed into the handlebar.  He immediately experienced abdominal pain, which improved over the next several hours.  Vital signs are normal.  Physical examination shows epigastric tenderness without rigidity or rebound tenderness.  Bowel sounds are normal.  Bedside ultrasonography reveals no intraperitoneal free fluid.  Plain abdominal radiograph shows gastric dilation with scant distal gas.  Laboratory results are as follows:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient with blunt abdominal trauma (BAT) has a delayed presentation of postprandial abdominal pain with signs of proximal small-bowel obstruction (eg, bilious emesis, gastric dilation with scant distal gas), findings concerning for duodenal hematoma (DH). Rapid compression of the duodenum (eg, handlebar impact) against the vertebral column during BAT can injure blood vessels between the submucosal and muscularis layers, causing bleeding and hematoma formation. As the hematoma progressively expands over the subsequent 24-48 hours, partial or complete obstruction of the duodenal lumen can develop. As a result, patients typically have a delayed presentation with suggestive symptoms (eg, epigastric pain, bilious emesis) and radiographic findings (eg, gastric dilation with scant distal gas). Children typically have less protective abdominal walls (eg, thinner musculature, less adipose tissue) and are therefore more vulnerable to developing DHs from BAT. CT imaging of the abdomen can confirm the diagnosis. DHs are typically managed with bowel rest, nasogastric decompression, and parenteral nutrition. The majority resolve with nonoperative management, but percutaneous drainage or surgery may be considered for DHs that persist beyond a few weeks. (Choice B) Liver laceration is one of the most common complications of BAT but typically results in abnormal vital signs (eg, tachycardia), right upper quadrant tenderness, and intraperitoneal free fluid (blood). This patient's slightly elevated bilirubin is likely due to hematoma resorption (eg, hemoglobin breakdown to bilirubin). (Choice C) Pancreatic injury may result from BAT rapidly compressing the pancreas against the vertebral column. Resulting pancreatic leakage may form a pseudocyst, with the possible symptoms of emesis and epigastric tenderness. However, pseudocysts typically develop over weeks rather than 2 days. (Choice D) Pyloric stenosis can cause emesis and gastric dilation; however, emesis is nonbilious because the obstruction is at the gastric outlet, proximal to the ampulla of Vater (ie, bile inflow). In addition, pyloric stenosis typically presents within the first 2 months of life and would be extremely rare in a child age 10. (Choice E) Although BAT can cause small-bowel perforation acutely or subacutely (eg, small-bowel contusion progressing to ischemic necrosis), perforation more commonly presents with a systemic inflammatory response (eg, fever, tachycardia) and peritonitis (eg, rigidity). Educational objective: Rapid compression of the duodenum against the vertebral column during blunt abdominal trauma may result in a duodenal hematoma. Affected patients commonly have epigastric pain and emesis 24-48 hours postinjury because the hematoma expands to obstruct the duodenal lumen. CT scan confirms the diagnosis. References: Pancreatic and duodenal trauma in children. (http://www.ncbi.nlm.nih.gov/pubmed/31110846) Management of traumatic duodenal hematomas in children. (http://www.ncbi.nlm.nih.gov/pubmed/25976857)

A 10-Year-Old Boy Is Brought to the Emergency Department Due