A high index of suspicion of duodenal injuries is the key to dealing with patients with a trauma suggestive of this type of injury and typical physical findings. Penetrating duodenal injury can be expeditiously diagnosed during explorative laparotomy. Initially, hemostasis should be prioritized. Once bleeding and major contamination control is achieved, the duodenum should be the next injury to be addressed. When duodenal injuries are suspected based on intraoperative findings, such as hepatic flexure, stomach or liver injuries, or local signs such as bruised duodenum, saponification, or bile leak, full kocherization is performed to assess the integrity of the duodenum. Table 10.2 shows the incidences of other organ injuries often associated with duodenal injury.

In blunt injury, patients with highly suggestive mechanisms, such as a direct blow to epigastrium, or seat belt injury with fracture of thoracolumbar junction, need to be carefully considered for duodenal injury. Physical findings such as tissue contusion in the upper abdomen, lower rib fractures, or disproportionally severe epigastric pain may arouse suspicion of duodenal injury. It is of note that blood tests, including lipase and liver function tests, have no diagnostic value in predicting duodenal injury.

Nonoperative management (NOM) of patients with blunt abdominal trauma and normal hemodynamics, in the absence of obvious bowel injuries, is usually successful but poses a risk of missing duodenal injuries. NOM relies heavily on computed tomography (CT) to exclude hollow viscus injuries. Unexplained peritoneal free fluid in CT is often described as an indicator for small bowel and duodenal injury. Nevertheless, it has not proved to be a reliable sign. Ballard et al. reported that 27 % of duodenal injuries were missed despite a negative initial CT and advocated that CT with oral and IV contrast should be performed [12]. A retrospective study by Allen et al. demonstrated that subtle CT findings such as isolated free fluid or unusual bowel morphology were retrospectively observed in 83 % of the patients with delayed diagnosed duodenal injuries [6, 7]. More importantly, 23 % of those injuries had normal initial CT studies. False-positive results sometimes occur [13, 14]. Rodriguez et al. concluded that a therapeutic laparotomy was performed in only 22 % of those patients with positive CT scan [13]. One study by Mirvis et al. demonstrated that the accuracy of prospective CT scan was only 59 % (10 out of 17), but when the images were retrospectively interpreted, it increased up to 88 % [14]. Considering the poor sensitivity of CT for hollow viscus injuries, the elusive characteristic of this injury, and the deleterious consequences of delayed diagnosis, it should be emphasized that the diagnosis of duodenal injury should be based on the combination of mechanisms, clinical findings, and radiological findings. Careful inspection and interpretation by experienced radiologists and surgeons are required to detect initial duodenal injury [15].

Until two decades ago, diagnostic peritoneal lavage (DPL) was the main diagnostic tool for abdominal trauma. Intra-abdominal bleeding is now detected or excluded with ultrasound, namely, FAST (focused assessment with sonography for trauma). The role of DPL is now limited to the diagnosis of hollow viscous injury when the multi-slice CT scan findings are ambiguous or suspicious. Due to the mainly retroperitoneal location of the duodenum, DPL is unreliable in the diagnosis of duodenal injuries [7].

Considering a lack of specific tests for excluding duodenal injuries, a diagnostic explorative laparotomy is still often required. We must emphasize that a negative laparotomy carries minimal complication especially when compared to a delayed diagnosis of duodenal injury. Duodenal injuries are often associated with other intra-abdominal injuries (liver, pancreatic, or bowel) and retroperitoneal injuries (kidney or major vessel), and intraoperative diagnosis of these injuries is also a possibility.

Historically, factors contributing to increased morbidity and mortality in patients with duodenal injuries are as follows: (1) blunt mechanism or gunshot wound, (2) a laceration or defect larger than 75 % of circumference, (3) delay to treatment of more than 24 h, and (4) injuries to the first or second portion of duodenum [16]. These determinants are briefly discussed below:

More recently, in a similar study of 55 patients, AAST grade, hemodynamic status, intraoperative cardiac arrest, and operative time were all strongly predictive of mortality on multivariate analysis, while AAST grade represented the only independent prognostic factor predictive of overall morbidity [22].