Fibrotic stenosis of the third duodenum complicating a post-traumatic pancreatitis, about a rare case.

Dear Editor,

Fibrous stenosis post-traumatic duodenum is exceptional. In fact, most duodenal hematomas resolve spontaneously without sequelae, and less than a dozen sightings have been reported in literature. This pathology presents diagnostic, therapeutic, and prognostic problems.[1]

A 36-years-old male patient with no medical history was victim of an accident at work, which caused an epigastric abdominal contusion. At his admission, the hemodynamic status was stable. Abdominal examination found epigastric tenderness and a normal temperature. Digital rectal examination was normal. The WBC showed a slight leukocytosis at 12000e/mm3. An abdominal ultrasonography showed a few intra-peritoneal liquid. The pancreas has not been explored. The abdominal computed tomography (CT) found a hematoma of the duodenal wall with increased volume of the pancreas, without pneumoperitoneum. A conservative treatment was undertaken with diet and parenteral nutrition, analgesia by paracetamol, and monitoring of hemodynamic and abdominal status. The patient had a good evolution, with regression of pain and no fever. The diet was resumed on day four of the accident. The patient was released the eighth day of trauma.

A month later, he was re-admitted for post-prandial and bilious vomiting and functional renal failure. An abdominal CT showed regression of duodenal hematoma with duodenal dilatation suggesting a cicatricial stenosis of the third duodenum [Figure 1]. Gastroduodenal opacification confirmed stenosis of the third duodenum with no opacification of this duodenum and duodenal and gastric dilatation upstream of the stenosis [Figure 2]. After rehydration and implementation condition, the patient was operated by a supra-umbilical midline incision. The exploration showed a fibrous stenosis of the 3rd duodenum. A trans-mesocolic gastrojejunal anastomosis was performed. The post-operative course was uneventful. A post-operative follow-up of 12 months showed significant improvement in symptoms with marked regression vomiting.

Figure 1

Abdominal CT showing dilatation of the stomach, duodenum 1st and 2nd with 3rd duodenum stenosis

Figure 2

Gastroduodenal opacification confirmed stenosis of the third duodenum with no opacification of this duodenum and duodenal and gastric dilatation upstream of the stenosis

Duodenal trauma during abdominal contusions is rare, because of the rigidity of the duodenum and its deep retro-peritoneal location. These lesions are often contusions, hematomas, and rarely failures or perforations.[1] After the trauma, hematoma of the duodenal wall may resolve spontaneously two weeks on an average after the trauma.[2] The duodenal wall hematoma may exceptionally move towards a luminal narrowing as is the case of our observation. Fibrous stenosis may occur early or years after the trauma.[34] We note sometimes the presence of a pseudocyst adjacent to the stenosis.[4] Computed tomography (CT) is the exam to do in a duodenal trauma,[5] it can better manage conservative treatment and show the complications. Serial sections focused on the duodenum can eliminate an early duodenal perforation, highlight a hematoma of the duodenal wall, and evaluate associated lesions. It also allows classifying pancreatic trauma frequently associated.[35] The treatment of duodenal stenosis is often digestive gastrojejunal bypass. Retroperitoneal fibrosis occasionally may require pancreaticoduodenectomy, with greater mortality and morbidity.[3]