Cas N°5 : numéro d'entrée 363745/19
VI. Complications – évolution
4. Traitement des complications :
a. Sténoses duodénales
Chez l’enfant les sténoses duodénales sont fréquentes. Elles sont dues à des hématomes duodénaux intra muraux qui, en se résorbant, aboutissent à une sténose responsable d’un syndrome occlusif haut.
Le début de la symptomatologie peut être retardé jusqu’à un mois après le traumatisme [108].
En principe, le traitement d’un hématome duodénal est un traitement conservateur (89% à 94%). Il consiste en une décompression en ayant recours à une aspiration naso-gastrique et une alimentation parentérale [58,60,96] [108,109].
Le traitement peut être chirurgical d’emblée pour certaines équipes ou après échec du traitement conservateur. Il consiste au minimum à une évacuation de l’hématome ou à la réalisation d’une dérivation gastro-jéjunale ou mieux duodénojéjunale [110].
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Le diagnostic de lésion duodénale isolée peut être difficile en raison de sa rareté, de sa localisation anatomique et de l'absence de signes et symptômes spécifiques.
Les traumatismes duodénaux de l’enfant posent un réel défis pour le médecin que ce soit sur le plan diagnostic ou thérapeutique, le retard diagnostic peut engendrer de graves conséquences et causer le décès. Quel que soit l’intensité du traumatisme, il doit être suspecté dans les plus brefs délais afin de diminuer la morbidité et la mortalité qui lui est associées.
L’imagerie doit apporter le diagnostic de certitude de l’atteinte duodénale suspectée à l’examen clinique et biologique, préciser l’éventuelle existence de lésions associées (une atteinte pancréatique) et surtout de parvenir au diagnostic d’une éventuelle perforation duodénale.
Le traitement conservateur non chirurgical reste l’attitude de première intention lorsque le diagnostic de traumatisme duodénal est posé, la prise en charge non opératoire a une capacité d’évolution spontanée favorable importante, les drainages scanno-guidés sont recommandés, la chirurgie n’est à envisager qu’en dernier recours.
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Résumé
Titre : Traumatismes duodénaux chez l’enfant : à propos de 5 cas Auteur : Alaeeddine HMINA
Directeur de thèse : Pr. ZERHOUNI Hicham Mots clé : Traumatisme – Duodénum – Enfant
L'histoire naturelle et la prise en charge des lésions duodénales pédiatriques sont incomplètement décrites. Cette étude visait à examiner le mécanisme des blessures, la prise en charge et les résultats d'une série de traumatismes duodénaux pédiatriques.
Il s’agit d’une étude rétrospective des dossiers effectuée pour une période de 10 ans chez des enfants traités pour des blessures duodénales au niveau du Service des Urgences Chirurgicales Pédiatriques de l'Hôpital d'Enfants de Rabat.
Les traumatismes duodénaux sont rares : 5 cas sur 850 traumatismes abdominaux soit 0,6%, de prédominance masculine (3 garçons sur 5 dans notre étude), le tableau clinique n’est pas spécifique, fait le plus souvent de douleurs abdominales et de vomissements.
Les traumatismes duodénaux ont été fermés pour l’ensemble des malades, avec des mécanismes très variés.
Sur le plan radiologique, l’échographie et la tomodensitométrie ont permis d’aboutir aux diagnostics :
L’échographie a permis le diagnostic dans 2 cas et la tomodensitométrie dans les 3 autres cas, aboutissant au diagnostic d’un hématome duodénal pour 3 cas et une rupture duodénale dans 2 cas.
Le traitement conservateur non opératoire a été entrepris chez les malades présentant un hématome pariétal duodénal. Pour les deux cas de perforation duodénale, l’indication chirurgicale s’est posée. Un malade a bénéficié d’une suture simple et un autre a bénéficié d’une exclusion duodénale et anastomose gastro-jéjunale
Le traitement médical a été symptomatique, comprenant des antalgiques dans 3 cas et instauration d’une antibiothérapie dans un seul cas en pré opératoire avec une bonne évolution sous surveillance.
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Summary
Title: Child Duodenal Trauma: About 5 Cases Author: Alaeeddine HMINA
Thesis Director: Prof. ZERHOUNI Hicham Keywords: Trauma - Duodenum - Child
The natural history and management of pediatric duodenal lesions are incompletely described. The purpose of this study was to examine the mechanism of injury, management and the results of a series of pediatric duodenal trauma.
This is a retrospective study of records carried out over a period of 10 years in children treated for duodenal injuries at the level of the Pediatric Surgical Emergency Department of the Rabat Children's Hospital.
Duodenal trauma is rare: 5 out of 850 cases of abdominal injuries (0.6%), male-dominated (3 out of 5 boys in our study), the clinical picture is not specific, most often causeabdominal pain and vomiting.
Duodenal traumas have been closed for all patients, with a wide variety of mechanisms. On the radiological level, ultrasound and CT scans led to diagnoses:
Ultrasound enabled diagnosis in 2 cases and CT scan in the other 3 cases, resulting in the diagnosis of a duodenal hematoma in 3 cases and a duodenal rupture in 2 cases.
Non-operative conservative treatment was initiated in patients with a duodenal parietal hematoma. For both cases of duodenal perforation, the surgical indication arose. One patient received a simple suture and another received a duodenal exclusion and gastro-jejunal anastomosis
Medical treatment was symptomatic, including painkillers in 3 cases and introduction of antibiotic therapy in a single preoperative case with good progression under supervision.
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ﺺﺨﻠﻣ
ناﻮﻨﻌﻟا ﻲﻟاﻮﺣ :لﺎﻔطﻷا ﺪﻨﻋ ﺮﺸﻋ ﻲﻨﺛﻻا ﺔﻣﺪﺻ : 5 تﻻﺎﺣ ﻒﻟﺆﻤﻟا ﻨﯿﻤﺣ ﻦﯾﺪﻟا ءﻼﻋ : ﺔ فﺮﺸﻤﻟا ذﺎﺘﺳﻷا : ﻟا مﺎﺸھ ﻲﻧﻮھرﺰ تﺎﻤﻠﻜﻟا ﺔﯿﺳﺎﺳﻷا ﺔﻣﺪﺼﻟا : ﺮﺸﻋ ﻲﻨﺛﻻا -ﻞﻔﻄﻟا ﯾرﺎﺘﻟا ﻒﺻو ﻢﺘﯾ ﺮﺸﻋ ﻲﻨﺛﻻا تﺎﻓﻵا ةرادإو ﻲﻌﯿﺒﻄﻟا ﺦ ﺔﺳارﺪﻟا هﺬھ ﻦﻣ ضﺮﻐﻟا نﺎﻛو .ﻞﻣﺎﻛ ﺮﯿﻏ ﻞﻜﺸﺑ لﺎﻔطﻸﻟ ﻟ ﺮﺸﻋ ﻲﻨﺛﻻا تﺎﻣﺪﺼﻟا ﻦﻣ ﺔﻠﺴﻠﺳ ﺞﺋﺎﺘﻧو ةرادﻹاو ﺔﺑﺎﺻﻹا ﺔﯿﻟآ ﺔﺳارﺪﻟ ىﺪ لﺎﻔطﻷ ىﺪﻣ ﻰﻠﻋ ﺖﯾﺮﺟأ ﻲﺘﻟا تﻼﺠﺴﻠﻟ ﺔﯾدﺎﻌﺘﺳا ﺔﺳارد هﺬھ 10 ﺮﺸﻋ ﻲﻨﺛﻻا تﺎﺑﺎﺻإ ﻦﻣ اﻮﺠﻟﻮﻋ ﻦﯾﺬﻟا لﺎﻔطﻸﻟ تاﻮﻨﺳ لﺎﻔطﻸﻟ طﺎﺑﺮﻟا ﻰﻔﺸﺘﺴﻣ ﻲﻓ لﺎﻔطﻸﻟ ﺔﯿﺣاﺮﺠﻟا ئراﻮﻄﻟا ﻢﺴﻗ ىﻮﺘﺴﻣ ﻰﻠﻋ :ةردﺎﻧ ﺔﯿﺋﺎﻨﺜﻟا ﺔﻣﺪﺼﻟا 5 ﻞﺻأ ﻦﻣ 850 ﻦﻄﺒﻟا ﻲﻓ ﺔﺑﺎﺻإ ) ٪ 0.6 ( ) رﻮﻛﺬﻟا ﺎﮭﯿﻠﻋ ﻦﻤﯿﮭﯾ ، 3 ﻞﺻأ ﻦﻣ 5 ﻲﻓ دﻻوأ ﺎﻣ ﺎﺒﻟﺎﻏو ،ةدﺪﺤﻣ ﺖﺴﯿﻟ ﺔﯾﺮﯾﺮﺴﻟا ةرﻮﺼﻟا ،(ﺎﻨﺘﺳارد ﻲﻓ ﻞﺜﻤﺘﺗ ءﻲﻘﻟاو ﻦﻄﺒﻟا مﻻآ ﻻا تﺎﻣﺪﺻ ﻲﻨﺛ يﺮﺸﻋ ﺖﻧﺎﻛ ﺔﻘﻠﻐﻣ ﻟ ىﺪ تﺎﯿﻟﻵا ﻦﻣ ﺔﻌﺳاو ﺔﻋﻮﻤﺠﻣ ﻊﻣ ، ﻰﺿﺮﻤﻟا ﻊﯿﻤﺟ ﺺﯿﺨﺸﺘﻟا ﻰﻟإ لﻮﺻﻮﻟا بﺎﺴﺤﻟاو ﺔﯿﺗﻮﺼﻟا قﻮﻓ تﺎﺟﻮﻤﻟﺎﺑ ﻲﻌﻄﻘﻤﻟا ﺮﯾﻮﺼﺘﻟا حﺎﺗأ ، ﻲﻋﺎﻌﺷﻹا ىﻮﺘﺴﻤﻟا ﻰﻠﻋ ﻜﻣ ﺔﯿﺗﻮﺼﻟا قﻮﻓ تﺎﺟﻮﻤﻟا ﺘﻨ ﻨ ﺎ ﻦﻣ ﻲﻓ ﺺﯿﺨﺸﺘﻟا ﺘﻟﺎﺣ ﻦﯿ ﻲﻓ ﻲﻌﻄﻘﻤﻟا ﺮﯾﻮﺼﺘﻟاو 3 ﻰﻟإ ىدأ ﺎﻤﻣ ، ىﺮﺧأ تﻻﺎﺣ ﻣد مرو ﺺﯿﺨﺸﺗ ﻲﻓ ﺮﺸﻋ ﻲﻨﺛﻻا يﻮ 3 ﻲﻓ ﺮﺸﻋ ﻲﻨﺛﻻا قﺰﻤﺗو تﻻﺎﺣ ﻟﺎﺣ ﺘ ﻦﯿ ﺔﺒﺴﻨﻟﺎﺑ .ﺮﺸﻋ ﻲﻨﺛﻻا يراﺪﺠﻟا يﻮﻣد مرو ﻦﻣ نﻮﻧﺎﻌﯾ ﻦﯾﺬﻟا ﻰﺿﺮﻤﻟا ﻲﻓ ﻲﺣاﺮﺠﻟا ﺮﯿﻏ ﻆﻓﺎﺤﻤﻟا جﻼﻌﻟا أﺪﺑ ﺪﻗو ﺸﻋ ﻲﻨﺛﻻا دﺎﻌﺒﺘﺳا ﻦﻣ ﺮﺧآ دﺎﻔﺘﺳاو ﺔﻄﯿﺴﺑ ﺔطﺎﯿﺧ ﻦﻣ ﺾﯾﺮﻣ دﺎﻔﺘﺳا .ﺔﯿﺣاﺮﺠﻟا ﺮﺷﺆﻣ ﺄﺸﻧ ، ﺮﺸﻋ ﻲﻨﺛﻻا ﺐﻘﺛ ﻦﻣ ﻦﯿﺘﻟﺎﺤﻟ ﺮ .ءﺎﻌﻣﻷاو ةﺪﻌﻤﻟا ةﺮﻏﺎﻔﻣو ﻲﻓ تﺎﻨﻜﺴﻤﻟا ﻚﻟذ ﻲﻓ ﺎﻤﺑ ، ضاﺮﻋﻷا ﻦﻣ ﻲﺒﻄﻟا جﻼﻌﻟا نﺎﻛ 3 ﺔﻟﺎﺣ ﻲﻓ ﺔﯾﻮﯿﺤﻟا تادﺎﻀﻤﻟﺎﺑ جﻼﻌﻟا ءﺪﺑو تﻻﺎﺣ .فاﺮﺷﻹا ﺖﺤﺗ ﺪﯿﺟ مﺪﻘﺗ ﻊﻣ ﺔﺣاﺮﺠﻟا ﻞﺒﻗ ةﺪﺣاو .ﻰﺿﺮﻤﻟا ﻊﯿﻤﺠﻟ ﺔﯿﺗاﻮﻣ ﻦﻄﺒﻟا ﻮﻤﻧ نﺎﻛو83
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