A 34-year-old male presented to the emergency department with severe abdominal pain following a workplace accident. Approximately 1 hour before admission, the patient had fallen backward while climbing a ladder and had been struck directly in the epigastric area by a heavy object. After the accident, he awoke with no memory loss and immediately experienced severe abdominal pain and dizziness without dyspnea or chest pain. The patient was transported to Thai Nguyen National Hospital in Vietnam by family members. Upon arrival, his condition was assessed according to the Advanced Trauma Life Support algorithm. The airway was patent and bilateral breath sounds were clear. Heart rate was 91 beats per minute, blood pressure 130/80 mmHg, and respiratory rate 19 breaths per minute. He was conscious and lucid, with no neurologic deficits. He had no significant medical history or known drug allergies.

Abdominal examination revealed severe pain, bruising, and skin abrasions in the epigastrium (≈ 3 × 5 cm), accompanied by guarding and absent bowel sounds. Lumbar examination showed mild pain without bruising, normal limb movement, and no suspicion of spine injury. Blood tests demonstrated a white-blood-cell count of 16.49 × 10⁹/L; lipase, amylase, and other parameters were within normal limits. A Focused Assessment with Sonography for Trauma (FAST) examination detected a small amount of free fluid in Morison’s pouch, around the spleen, and in the Douglas pouch, with no solid-organ injury. Contrast-enhanced computed tomography (CT) of the abdomen revealed free air in the peritoneal and retroperitoneal spaces, a small volume of free fluid, soft-tissue infiltrates, and air bubbles adjacent to D4 (Figure 1). Chest radiography was normal and showed no spinal injury.

Figure 1

Based on clinical findings, the patient exhibited peritoneal signs requiring surgery, together with CT evidence of free intraperitoneal and retroperitoneal air without solid-organ injury. A preliminary diagnosis of hollow-viscus perforation secondary to blunt abdominal trauma was made. The presence of retroperitoneal air and infiltration around D4 suggested a duodenal injury, considered a poor prognostic indicator.

Figure 2

Figure 3

Laparotomy was performed 3 hours after arrival. A midline incision (~ 20 cm) extending above and below the umbilicus was used. A large volume of digestive fluid was found in the peritoneal cavity. The lesser curvature of the stomach had a 3 × 5 cm rupture (Figure 2). After a Kocher maneuver, the pancreas and D1–D3 segments of the duodenum were intact, but the fourth part (D4) was lacerated along approximately 40 % of its circumference, with sharp, non-crushed edges (Figure 3).

No additional intra-abdominal injuries were identified. The gastric defect was debrided and closed in two layers. At the duodenal site, the Treitz ligament was divided, and D3–D4 were mobilized to expose the lesion. The wound edges were debrided and sutured in two layers (Figure 4). Approximately 40 cm distal to the duodenal repair, a feeding jejunostomy was created. The peritoneal cavity was irrigated with 0.9 % saline. Two F16 drains were placed beneath the duodenal repair and two F16 drains in the Douglas pouch; a nasogastric decompression tube was also inserted.

Figure 4

Nutrition was provided via jejunostomy for the first 10 post-operative days. The nasogastric tube was removed and oral feeding began on post-operative day 11. Clinical status and laboratory tests remained normal. The patient experienced no complications and was discharged home after 13 days.

Duodenal injuries, although rare, are associated with high mortality and complication rates2, 7. Because of their rarity, clinicians may overlook them after blunt abdominal trauma, leading to delayed diagnosis and serious consequences.

Our case report demonstrates that primary repair, supplemented with extensive abdominal drainage and a feeding jejunostomy, is a feasible and effective method for treating uncomplicated D4 duodenal injuries. This finding supports the utility of primary repair as a viable option for selected cases—particularly those without significant tissue loss or other complications—offering a less complex yet effective management strategy. Clinicians confronting similar rare injuries should consider this approach, as it can yield favorable outcomes and expedite recovery, even in resource-constrained settings.

AAST: American Association for the Surgery of Trauma, CT: Computed Tomography, D4: Fourth portion of the Duodenum, FAST: Focused Assessment with Sonography for Trauma, MRI: Magnetic Resonance Imaging, SCARE: Surgical CAse REport guidelines

None.

S.T.D.: Concept and design, data interpretation and analysis, drafting, revision, and approval of final manuscript. S.H.T and H.D.H: Design, data collection, data interpretation and analysis, drafting, revision, and approval of the final manuscript. All authors read and approved the final manuscript.

None.

Data availability statement: The data that support the findings of this case report are available upon reasonable request from the corresponding author, with appropriate ethical considerations for patient privacy.

Ethical approval was waived by the institutional policy of Thai Nguyen National Hospital for retrospective case reports that do not involve identifiable patient information or interventions. Decision No. 478/qd-bv Dated February 24, 2024

Written informed consent was obtained from the patient’s mother for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

The authors declare that they have used generative AI and/or AI-assisted technologies in the writing process before submission, but only to improve the language and readability of their paper.

The authors declare that they have no competing interests.