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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 437-439
A rare case of pancreatic injury: A case report


Department of Radiodiagnosis and imaging, Kasturba Medical College Hospital, Attavar, Mangalore -575001, Karnataka, India

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Date of Submission30-Nov-2006
Date of Acceptance10-Dec-2006
 

Keywords: pancreatic injury, blunt abdominal trauma, grading of pancreatic injury

How to cite this article:
Mahale A, Gupta A, Paudel K. A rare case of pancreatic injury: A case report. Indian J Radiol Imaging 2006;16:437-9

How to cite this URL:
Mahale A, Gupta A, Paudel K. A rare case of pancreatic injury: A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:437-9. Available from: http://www.ijri.org/text.asp?2006/16/4/437/32239
Pancreatic injury occurs in less than 5% of major abdominal injuries [1]. Two thirds of pancreatic injuries are associated with penetrating abdominal trauma and one third associated with blunt abdominal trauma [2]. An early diagnosis of pancreatic trauma can be challenging and difficult because of the lack of correlation between the initial presenting features, radiological and laboratory findings, and the severity of the trauma. Caused by compression of the pancreas between the vertebral column and exteral compression, these injuries were extremely difficult to detect in the yesterdyears, but have now become easier to pick up with the advent of cross sectional imaging especially the computed tomography(CT) scan [3]. Morbidity and mortality increases with associated injury to other abdominal organs and vascular structures as well as with delay in diagnosis. We present a rare case of isolated pancreatic injury in a six- year old female.


   Case Report Top


A 6-year- old girl presented to the emergency department with history of blunt injury to abdomen. She has pain in the epigastrium, which was gradually increasing in intensity. She also complained of repeated bilious vomiting and distension of abdomen. Clinical examination revealed an ill-looking patient with increased heart rate and respiratory rate. She was apyrexic, conscious, well oriented. Abdominal examination revealed tenderness and guardness in the epigastrium. On auscultation, chest was clear and bowel sound was absent. All examinations of the head and eyes are normal except laceration of frontal scalp and ecchymosis of eyes were present. ENT and eyes examination revealed normal findings. Both chest and abdominal erect plain radiographs were normal. The white blood cells count and liver function tests are within normal limits. Serum amylase level was 139 U/L (normal limit- up to 95U/L). CT head did not reveal any focal lesions in the brain.

An urgent ultrasound scan of abdomen showed a bulky inhomogenous pancreas with few hypoechoic areas. The largest one at the level of head of the pancreas was 2.5 cm and 1.1 cm [Figure - 1]. A thin linear hypoechoic lesion was noted in the tail of the pancreas showing breech of its outline. A linear hyperechogenicity anterior to left kidney is noted on ultrasound. A diagnosis of pancreatic grade III pancreatic injury was made based on ultrasound findings.

A CT scan of the abdomen revealed a vertical tear at the tail of pancreas [Figure - 2]. The main pancreatic duct was intact. CT revealed a non-enhancing hyperdense lesion in the body of the pancreas signifying a relatively fresh hematoma. Also confirmed was a fluid collection anterior to the body and tail of the pancreas. The rest of the abdominal viscera were normal.

Suturing of the scalp laceration was done and conservative line of management was initiated for the pancreatic injury. Nasogatric tube suction, antibiotic, IV alimentation and H2- receptor antagonist were initiated with close observation of her general condition and vital signs. Her pain settled down and she made an uneventful recovery. Oral feeds were started after one week of admission firstly with liquids and then semisolid and finally solid foods.


   Discussion Top


Pancreatic injury is a rare complication in patients with multiple injuries, usually associated with blunt or penetrating abdominal trauma [4]. Although the deep, central and reroperitoneal location of the pancreas usually protects it from injury, this anatomic location is responsible for the diagnostic challenge. In a patient with trauma from an anterior-posterior force vector with deceleration and an anterior truncal seat belt mark, pancreatic injury should also be considered in addition to aortic and small bowel injuries [5]. Pancreatic injury can range from minor contusions and hematoma to major lacerations or fractures with associated pancreatic duct injury according to severity is described in table 1 [6].

Initial serum amylase levels carry a low sensitivity for the prediction of pancreatic injury. However, persistently elevated or rising serum and urinary amylase levels are more reliable indicators of pancreatic injury [6]. Abdominal radiograph may show retroperitoneal air and a rupture duodenum. However, in our patient, these findings were negative.

Ultrasound very easily detects the fluid collections/ pseudocysts associated with pancreatic injury which are seen to be hypoechoic, and usually in relation to the pancreas, often extending into the lesser sac [3]. Post-traumatic pancreatitis may reveal an enlarged hypoechoic pancreas. Bulky inhomogenous pancreas and few foci of collections along the subpyloric, anterior pararenal and, pancreatic tail regions with anterior renal hematoma were present on ultrasound in our patient.

In patients with blunt injury to the pancreas, the Computed tomography(CT) scan provides the simplest and the least invasive diagnostic modality available at this time to aid in the detection of a stable blunt pancreatic injury [7]. Features of pancreatic injury include pancreatic edema or swelling and fluid collections within or behind the peritoneum or in he lesser peritoneal sac. CT is not suitable in patients who are haemodynamically unstable or who have a penetrating trauma in which the decision to operate has been made. CT can reportedly pick up injury to pancreas in as many as 85% cases [3]. Contusions appear as low attenuating nonenhancing areas contrasting with an enhancing pancreatic parenchyma while lacerations and fractures are seen as poorly enhancing linear lesions, often perpendicular to the long axis of the pancreatic body and neck [3]. Other CT findings include intraperitoneal fluid, extraperitoneal fluid, thickening of the anterior renal fascia, and gland enlargement has been evaluated as indicators of pancreatic injury [8].

Definite identification of pancreatic duct injury needs Endoscopic retrograde cholangiopancreaticography (ERCP) or Magnetic resonance cholangiopancreaticography (MRCP) in hemodynamically stable cases [3]. Accurate recognition of major pancreatic injury is essential because delay in diagnosis and associated vascular injuries are largely responsible for the high morbidity and mortality.

Hemodynamically stable patients and in the absence of associated injuries, blunt injuries to the pancreas may be managed conservatively. Our patient was managed conservatively with closely monitoring of her general condition and vital signs. However, a patient who continues to have pain or who develops symptoms of pancreatic injury should be thoroughly reassessed for pancreatic injury and operative intervention [3]. In most cases of pancreatic injury, surgical intervention is not required. If exploratory laparotomy is carried out, ductal damage may be visualized directly. Pancreatic resection is usually the most suitable treatment if CT scan or ERCP show that the duct has been damaged or transected.

Minor or isolated pancreatic injury recovers well. Severe injuries have poor prognosis due to frequent association with other injuries [3]. Complications of pancreatic injury are bleeding, pancreatic abscess, recurrent pancreatitis, fistula formation and pancreatic pseudocysts. Review ultrasound after 2 months of injury in our patient did not detect any focal lesions in the pancreas.

In conclusion, isolated pancreatic injury is very uncommon in children. Initial serum amylase level does not correlate with the severity of pancreatic injury. The majority of pancreatic injuries can be managed non-operatively. Patients with grade III pancreatic injury with stable vital signs can be managed conservatively. Blunt pancreatic injury should be diagnosed as early as possible to prevent the serious complications that can result from delay.

 
   References Top

1.Craig MH, talton DS, Hauser CJ, Poole GV, Pancreatic injuries from blunt trauma. Am Surg 1995;61:125-128.  Back to cited text no. 1    
2.Yeo CJ, Cameron JI. Exocrine pancreas. In: Townsend CM. Editor. Sebastian textbook of surgery, 16th ed. Harcourt Asia Ltd & WB Saunders and Co., 2001:457-472.  Back to cited text no. 2    
3.Khanna Lt Col V, Gualti Lt Col YS, Sreeram Col MN, Sharama R, A rare case of pancreatic injury: case report with an imaging perspective. Asian oceanian Journal of Radiology April-Sep 2004; 9:64-67.  Back to cited text no. 3    
4.Wright MJ, Stanski C, Blunt pancreatic trauma: a difficult injury. South Med J Apr 2000;63:598-604.  Back to cited text no. 4    
5.Buechester Kennan J, Blunt pancreatic trauma. South Med J 200; 43:383-385.  Back to cited text no. 5    
6.Hoyt DB, Coimbra R, Winchell RJ, Sebastian textbook of surgery, 16th ed. Harcourt Asia Ltd & WB Saunders and Co., 2001:334-335.  Back to cited text no. 6    
7.Cirillo RL JR, Kiniaris LG, Detecting blunt pancreatic injuries. J Gastrointest Surg 2002; 6:587-598.  Back to cited text no. 7    
8.Lane MJ, Mindelzum RE, Sandhu JS, et al, CT diagnosis of blunt pancreatic trauma: importance of detecting fluid between the pancreas and the splenic vein. AJR 1994; 168:833-835.  Back to cited text no. 8    

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Correspondence Address:
K Paudel
Department of Radio-diagnosis and imaging, Kasturba Medical College Hospital, Attavar, Mangalore - 575001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32239

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