Traumatic blowout of a duodenal diverticulum: A rare clinical finding

Duodenal diverticula are a common phenomenon routinely diagnosed during investigative imaging studies. A 64-year old female presented with multiple injuries after a motor-vehicle collision (MVC). CT scan confirmed renal, splenic and pulmonary trauma, with sacral and multiple rib fractures. A repeat CT scan was performed 8 h later due to extensive abdominal injuries and persistent tachycardia, and revealed the presence of retroperitoneal air suspicious for a duodenal injury. On exploratory laparotomy, a significant amount of retroperitoneal haemorrhage in the upper abdomen and a perforated retroperitoneal duodenal diverticulum at the antimesenteric border of the second portion of the duodenum were noted. A stapled diverticulectomy was performed. The patient recovered fully despite postoperative left sided hydronephrosis and continued to do well.Although duodenal diverticula are a common occurrence, their traumatic blow out is rare and has a high mortality rate. A duodenal diverticular blow out requires surgical intervention and stapled diverticulectomy is safe and feasible. The position of the diverticulum relative to the ampulla of vater has surgical implications. In the presence of diverticular-ampullary complex, resection is not advisable and serious consideration should be given to tube duodenostomy to control spillage or if technically feasible a roux-en Y duodenojejunostomy may be performed.The diverticular blow out in our case is likely due to a closed loop obstruction and duodenal compression caused by the lap seat-belt. The sudden force of impact during the MVC may have compressed the intra-abdominal viscera and caused an explosive rush of air into the lumen of the diverticulum, resulting in diverticular perforation.In a patient with multiple trauma, extra vigilance and judicious use of available resources in a timely fashion becomes imperative to identify such serious potentially life threatening conditions.