most commonly occur after penetrating abdoinal trauma

Penetrating injuries are frequently full-thickness perforations resulting in the spillage ofgastric contents.

blunt gastric injuries are rare, occurring in 0.05% of all blunt trauma

The proposed mechanism of blunt gastric rupture is an acute increase in intraluminal pressure from external forces that results in bursting of the gastric wall

Gastric injuries will often be identified on physical examination by the presence of peritonitis

Some gastric injuries are identified by CT or DPL but the value of these modalities is limited.

The most commonly missed gastric injury is the posterior wound of a totally penetrating injury

Injuries also can be overlooked if the wound is located within the mesentery of the lesser curvature or high in the posterior fundus

To delineate a questionable injury, the stomach can be digitally occluded at the pylorus while methylene blue-colored saline is instilled via a nasogastric tube

TREATMENNT

Partial gastrectomy may be required for destructive injuries, with resections of the distal antrum or pylorus reconstructed using a Billroth procedure.

Gastric wounds can be oversewn with a running single-layer suture line or closed with a stapler

destructive injuries to the stomach involving large portions of the gastric wall require a partial or even total gastrectomy. Reconstruction options include a Billroth I or II gastroenterostomy or creation of a Roux-en-Y esophagojejunostomy.

Duodenal injuries Duodenal injuries are uncommon The classic description is the abdomen being struck by a steering wheel or, in children, a bicycle handlebar.

Although duodenal injuries after penetrating trauma are found at laparotomy, their identification after a blunt mechanism can be challenging and therefore require a high index of suspicion to avoid missed injuries

The mainstay of evaluation for duodenal injury has become abdominal CT

Duodenal InjurieS Hematomas perforation (blunt blow-outs, lacerations from stab wounds, or blast injury from gunshot wounds).combined pancreaticoduodenal injuries

majority of duodenal hematomas are managed nonoperatively

A marked drop in nasogastric tube output heralds resolution of the hematoma, which typically occurs within 2 weeks;

If the patient shows no clinical or radiographic improvement within 3 weeks, operative evaluation is warranted

Patients with suspected associated perforation, suggested by clinical deterioration or imaging with retroperitoneal free air or contrast extravasation,

TREATMENT Small duodenal perforations or lacerations should be treated by primary repair using a running single-layer suture of 3-0 monofilament

Extensive injuries of the first portion of the duodenum (proximal to the duct of Santorini) can be repaired by debridement and end-toend anastomosis

defects in the second portion of the duodenum should be patched with a vascularized jejunal graft

Duodenal injuries with tissue loss distal to the papilla of Vater and proximal to the superior mesenteric vessels are best treated by Roux-en-Y duodenojejunostomy with the distal portion of the duodenum oversewn

injuries in the distal third and fourth portions of the duodenum (behind the mesenteric vessels) should be resected, and a duodenojejunostomy performed on the left side of the superior mesenteric vessels.

Pancreatic injuries Pancreatic injuries can result from direct penetration of the organ or through the transmission of blunt force energy to the retroperitoneum.

A commonly identified mechanism involves the crushing of the body of the pancreas between a rigid structure such as a steering wheel or seatbelt and the vertebral column.

Abdominal imaging with IV-enhanced cr can indicate the pancreatic injury bur the sensitivity is limited for parenchymal injury and pancreatic duct disruption

Pancreatic Injuries Because of their adjacent location, injuries to the duodenum are frequently associated with pancreatic injuries. these are rare in blunt and penetrating mechanisms

Optimal management of pancreatic trauma is determined by where the parenchymal damage is located and whether the intrapancreatic common bile duct and main pancreatic duct remain intact

Patients with pancreatic contusions (defined as injuries that leave the ductal system intact) can be treated nonoperatively or with closed suction drainage if undergoing laparotomy for other indications

Patients with proximal pancreatic injuries, defined as those that lie to the right of the superior mesenteric vessels, are also managed with closed suction drainage

Pancreatic duct disruption identify direct exploration of the parenchymal laceration, operative pancreatography ERCP, MRCP

Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation.

Injuries to the pancreatic head add an additional element of complexity because the intrapancreatic portion of the common bile duct traverses this area and often converges with the pancreatic duc

identification of intrapancreatic common bile duct disruption squeeze the gallbladder and look for bile leaking from the pancreatic wound.cholangiography, optimally via the cystic duct

Definitive treatment of this injury entails division of the common bile duct superior to the first portion of the duodenum, with ligation of the distal duct and reconstruction with a Roux-en-Y choledochojejunostomy

For injuries to the head of the pancreas that involve the main pancreatic duct but not the intrapancreatic bile duct, there are few option:

central pancreatic resection with Roux-en-Y pancreaticojejunostomy prevents pancreatic insufficiency.

Some injuries of the pancreatic head do not involve either the pancreatic or common bile duct; if no clear ductal injury is present, drains are placed

Rarely, patients sustain destructive injuries to the head of the pancreas or combined pancreaticoduodenal injuries that require pancreaticoduodenectomy

pancreatic resection continues to be advocated for major ductal disruption in the more distal pancreas.

injuries of the pancreatic body and tail.

In stable patients, spleen-preserving distal pancreatectomy should be performed

If the patient is physiologically compromised, distal pancreatectomy with splenectomy is the preferred approach

An alternative which preserves both the spleen and distal transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy

Pyloric exclusion is used to treat combined injuries of the duodenum and the head of the pancreas as well as isolated duodenal injuries when the duodenal repair is less than optimal