Quando un trauma apparentemente lieve provoca una lesione grave: perforazione duodenale isolata da manubrio di bicicletta

Traumatic duodenal injuries are rare in the paediatric population and isolated duodenal perforation (IDP) is even rarely reported. Delayed diagnosis and treatment may lead to severe complications. In Italy published literature on this topic is limited. A 14-year-old boy presented to the Emergency Room with abdominal pain and vomiting 30 minutes after a handlebar injury. On examination, he appeared in severe pain, pale and diaphoretic, but haemodynamically stable. The abdomen was tense, poorly compliant, tender, with guarding in the epigastrium, right upper quadrant and right flank. Laboratory tests showed elevated pancreatic lipase, with normal blood count and inflammatory markers. Abdominal ultrasound was inconclusive; abdominal X-ray showed no bowel distension or free air. The patient was evaluated by a general surgeon, who requested a contrast-enhanced computed tomography (CT) that revealed multiple retroperitoneal air bubbles and abundant free fluid. Due to evidence of upper gastrointestinal tract perforation, the patient was transferred to the paediatric surgery unit and underwent emergency exploratory laparoscopy with duodenorrhaphy, with successful recovery. A high index of suspicion is required to diagnose IDP in children. Vomiting and upper-quadrant abdominal pain are the most common symptoms, whereas elevated pancreatic lipase is less specific. Due to the retroperitoneal location of the duodenum, abdominal radiography and ultrasound are of limited diagnostic value. Timely contrast-enhanced CT is crucial for early diagnosis and management.