Guideline sources The following summarized guidelines for the evaluation and management of duodenal trauma are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES/AAST 2019). 1 Guidelines 1. Diagnostic investigations Ultrasound: Obtain extended FAST for detecting free fluid and solid organ injury. A Do not obtain routine ultrasound for the diagnosis of duodeno-pancreatic trauma. Consider obtaining contrast-enhanced ultrasound in stable patients with trauma with suspected pancreatic injury. D Computed tomography: obtain CT with IV contrast for the diagnosis of duodeno-pancreatic injuries in hemodynamically stable or stabilized patients with trauma. A Show 3 more Abdominal radiography: do not obtain abdominal plain films using water-soluble contrast in the early trauma scenario. D https://web.pathway.md/diseases/recl8ELt3MJZBACRX 1/4 6/29/23, 10:23 PM Duodenal trauma Pathway 2. Diagnostic procedures Peritoneal lavage: recognize that diagnostic peritoneal lavage does not improve the specificity of diagnosing duodeno-pancreatic injury, and it is sensitive but not specific for biliary tract injury. B 3. Medical management Non-operative management: use hemodynamic stability as the key factor in determining management strategy in patients with duodenal injury. B Show 4 more 4. Surgical interventions Exploratory laparotomy: perform exploratory laparotomy in hemodynamically unstable (WSES class IV) patients with a positive extended FAST. A Show 2 more Indications for surgery: perform immediate operative intervention in hemodynamically unstable (WSES class IV) patients and in patients with peritonitis, bowel evisceration, or impalement. B Show 4 more 5. Specific circumstances Pediatric patients: Manage pediatric patients with duodenal-pancreatic trauma by specialists with specific skills and only in trauma centers. B Obtain ultrasound with or without contrast enhancement as the diagnostic modality of choice for follow-up imaging in pediatric patients. Prefer MRI if cross-sectional imaging is required. B Pregnant patients: consider obtaining MRCP wherever available as the diagnostic modality of choice for new-onset signs and symptoms in pregnant patients. B Patients with pancreatic injury (evaluation): consider obtaining MRCP as a second-line noninvasive diagnostic modality to definitely rule out pancreatic parenchymal and pancreatic ductal injuries. Consider obtaining MRCP with hepatobiliary contrast for the diagnosis of suspected biliary injuries. B Show 4 more Patients with pancreatic injury (non-operative management): offer nonoperative management in all hemodynamically stable or stabilized patients with minor pancreatic injury (WSES class I, AAST grade I and some grade II) and gallbladder hematomas without perforation (WSES class I, AAST grade I) in the absence of other abdominal injuries requiring surgery. B Show 5 more https://web.pathway.md/diseases/recl8ELt3MJZBACRX 2/4 6/29/23, 10:23 PM Duodenal trauma Pathway Patients with pancreatic injury (operative management): consider performing drainage in patients with WSES class I (AAST grade I and some grade II) pancreatic injury found during exploratory laparotomy. C Show 8 more 6. Follow-up and surveillance Serial clinical assessment: perform serial clinical examination during follow-up after biliary and pancreatic-duodenal trauma. B Serial imaging assessment: Decide on the need and choice of follow-up imaging after discharge based on clinical symptoms (onset of abdominal distention, tenderness, fever, vomiting, jaundice) and in a multidisciplinary setting given the complexity and variability of traumatic injuries. B Obtain CT as the first-line follow-up imaging for new-onset signs and symptoms in adult patients. B Clinical findings Symptoms Past events Abdominal pain Motor vehicle accident Back pain Abdominal exam Epigastric pain Nausea Abdominal distension Vomiting Abdominal tenderness Peritoneal findings Vital signs Hypotension Signs of shock Imaging findings Free intraperitoneal fluid Pneumoperitoneum Studies 2023 Antimicrobial prophylaxis in pancreatoduodenectomy In adults undergoing open pancreatoduodenectomy for any indication, piperacillin-tazobactam was superior to cefoxitin with respect to the rate of postoperative surgical site infection within 30 days. Michael I D'Angelica et al. JAMA. 2023 May 9. https://web.pathway.md/diseases/recl8ELt3MJZBACRX 3/4 6/29/23, 10:23 PM Duodenal trauma Pathway References 1. Federico Coccolini, Leslie Kobayashi, Yoram Kluger et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 11;14 56. Open https://web.pathway.md/diseases/recl8ELt3MJZBACRX 4/4