D4 Duodenal Injury and Literature Review: A Case Report

Introduction: Duodenal injury from blunt abdominal trauma is rare and often requires complex repair methods. We report a case that was successfully managed with primary repair plus feeding jejunostomy. We also reviewed the literature on fourth-portion (D4) duodenal injuries. Case presentation: A 34-year-old man presented to the emergency department after a workplace accident with severe epigastric pain. His vital signs were stable. Abdominal examination revealed marked tenderness, bruising, superficial abrasions, generalized rigidity, and absent bowel sounds. Computed tomography of the abdomen showed free air in the peritoneal and retroperitoneal spaces. Four hours after injury, the patient underwent emergency laparotomy. We identified ruptures of the fourth portion of the duodenum and the stomach. Both defects were closed primarily, and a feeding jejunostomy was created. The postoperative course was uneventful. Clinical discussion: Rupture of the D4 segment can result from a fall onto the back, whereas gastric rupture often follows direct anterior impact. Free retroperitoneal air adjacent to D4 strongly suggests duodenal injury. We mobilized the surrounding tissue and performed a two-layer repair, supplemented by feeding jejunostomy to reduce the risk of duodenal leakage. Conclusion: Primary repair accompanied by wide abdominal drainage and feeding jejunostomy is a simple, safe, and effective option for uncomplicated D4 duodenal injuries.