The diagnosis of retroperitoneal injuries can be extremely complicated. As with intraabdominal injuries, symptomatology and physical findings may be subtle or completely absent at the time of patient presentation. Occasionally, retroperitoneal injuries do produce symptomatology such as abdominal pain, even if they are relatively insignificant, such as a small retroperitoneal hematoma. Even computed tomography (CT) may miss retroperitoneal injuries initially.
Duodenal injuries also can be asymptomatic at the time of presentation. Duodenal wall hematomas can produce relative gastric outlet obstruction with abdominal pain, nausea, and vomiting (Fig.. .252-1). Duodenal ruptures usually are contained within the retroperitoneum. They may present with abdominal pain, fever, and tenderness, although all of these may take hours or even days to become clinically obvious. Mechanism of injury should alert the clinician. Duodenal ruptures often occur from rapid increases in intraluminal pressure when both the pylorus and the proximal small bowel develop spasm. This is most often associated with high-speed vertical or horizontal decelerating trauma. Thus all such patients require some evaluation of the duodenum.
FIG. 252-1. Duodenal injury. CT scan demonstrating duodenal hematoma. Note the partial obstruction of the duodenum with an intramural hematoma. The injury resolved with nasogastric decompression and a short period of intravenous nutrition.
Pancreatic injuries also can be extremely subtle. They often accompany rapid decelerating injury. Pancreatic transection usually occurs in the midbody as the pancreas is displaced against the vertebral column. Thus unrestrained drivers who hit the steering column or bicyclists who hit the handlebars are at risk for pancreatic injury. Falls from height also can cause pancreatic injury.
The diagnosis of pancreatic injury can be elusive because many of these patients have very little in the way of symptoms at the time of presentation. Unfortunately, there are no biochemical or radiographic markers pathognomonic for the diagnosis. Elevations in serum amylase are nonspecific and not particularly useful. CT scanning may be normal initially. Relatively small pancreatic injuries can go on to become symptomatic days later. This is probably a result of leakage of pancreatic enzymes from the injured organ. Peripancreatic fluid develops and is activated, and a form of autodigestion occurs. Thus small pancreatic injuries ultimately may become larger and more symptomatic. These also can become superinfected with bacteria, producing a retroperitoneal abscess.
Urologic injuries often present with hematuria. Both the kidney and the bladder are well-vascularized organs, and even relatively minor injuries can produce an impressive amount of blood in the urine. Unfortunately, there are some injuries that may produce no hematuria. Ureteral injuries are common after penetrating trauma but also have been reported with blunt trauma, particularly vertical decelerating injuries. These injuries often present without hematuria. In addition, major renal hilar injuries such as vascular thrombosis and extraparenchymal vascular injury may have no hematuria at all ( Fig 2,52:2.).
FIG. 252-2. Blunt renal artery injury. CT scan demonstrates lack of enhancement of the left kidney. There is no evidence of perinephric hematoma or other sources of retroperitoneal blood loss. The patient underwent renal artery revascularization with a successful outcome.
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