Conservative management resolved duodenal obstruction caused by a retroperitoneal hematoma in a pediatric patient who became hemodynamically stable following seat belt–related trauma, according to a case report in Clinical Case Reports. Surgical repair of an associated gastric perforation was performed prior to nonoperative management.
Researchers described a boy aged 3 years and 9 months who sustained abdominal injury in a motor vehicle collision while restrained in a child seat. Initial computed tomography revealed free intraperitoneal air and a retroperitoneal hematoma measuring approximately 6 cm without active bleeding. Emergency laparotomy identified a 1-cm gastric perforation, which was repaired, while the hematoma was managed conservatively.
Despite initial signs of shock, the patient achieved hemodynamic stability by postoperative day 5 and was extubated on day 7. Gastric tube output increased to 890 mL/day by postoperative day 9, with persistent absence of bowel movements and reduced peristalsis.
Repeat imaging showed contrast retention in the stomach and duodenal bulb. Obstruction distal to the second portion of the duodenum was attributed to extrinsic compression from the hematoma.
Given these findings, physicians initiated total parenteral nutrition and continued nonoperative management with close clinical and imaging monitoring. Surveillance included gastric tube output, abdominal findings, and inflammatory markers while minimizing radiation exposure.
A contrast study on postoperative day 16 showed passage of contrast into the small intestine, indicating improvement. Oral intake resumed on day 19 and advanced to full feeding by day 23. The patient was discharged on postoperative day 36, with no abnormalities reported during 6 months of follow-up.
Retroperitoneal hematoma is an uncommon injury in pediatric patients, although children may be more vulnerable to clinically significant effects because of relatively larger abdominal organs and less intra-abdominal fat compared with adults. Conservative management is typically reserved for patients who are hemodynamically stable without ongoing bleeding or progressive anemia, but complications such as bowel obstruction require careful monitoring.
Published pediatric cases are limited, with prior reports describing surgical management within 1 to 4 days of injury. In contrast, this case suggests nonoperative management may be effective even when obstruction develops, with oral intake initiated 23 days after injury. In adult cases, oral intake generally resumes around 2 weeks following injury.
“Careful clinical and imaging monitoring allows nonoperative treatment and may help avoid complications associated with surgical intervention,” the researchers wrote.
The researchers reported no conflicts of interest.
Source: Clinical Case Reports
