Case Report

Isolated traumatic pancreatic rupture^? Abstract

Traumatic pancreatic rupture is associated with high morbidity and mortality. The diagnosis is difficult and usually accompanied with other injuries. We reported a 17-year-old adolescent boy who experienced this disease alone. The diagnosis was first suspected in ultrasonography and then confirmed by computed tomography. Endoscopic retrograde pancreatography showed his pancreatic duct was patent. He made an uneventful recovery after 10 days of hospitalization. Ultrasonography is well known for detecting the presence of hemoperitoneum in blunt abdominal trauma. Furthermore, it can be applied to the assessment of patients with posttraumatic abdominal pain. It provides a real-time, noninvasive, and inexpensive means for screening this kind of patients.

A healthy 17-year-old adolescent boy presented with abdominal pain for 1 day. In the previous day, he fell down accidentally from a 4-m-high area, with his back onto the ground. He felt abdominal discomfort since midnight. The next morning, the Epigastric pain gradually aggravated and progressed to his bilateral flank areas. Nausea was also reported. He was brought to our emergency department that night. His initial vital signs were as follows: body temperature, 36?C; pulse rate, 60/min; respiratory rate, 20/min; and blood pressure, 124/63 mm Hg. The physical examination revealed moderate epigastric tenderness. Others were unremarkable. Focused assessment sonography in trauma revealed neither ascites in Morison’s pouch nor pleural effusion. However, fluid accumulation around the pancreas was noted (Fig. 1). Abdominal computed tomog- raphy (CT) showed pancreatic body tear with peripancreatic fluid collection (Fig. 2). The biochemical studies showed elevated Pancreatic enzymes (amylase, 685 IU/L; lipase, 525 IU/L). The next day, the endoscopic retrograde pancreatography showed his pancreatic duct was patent. He received supportive treatment and made an uneventful recovery after 10-day hospitalization. He was well at clinical follow-up 3 months later with no specific complaints.

^? Article Presentation: Poster Presentation in 5th Mediterranean Emergency Medicine Congress on Sep 14th, 2009.

Pancreatic injuries occur infrequently after blunt abdo- minal trauma and are usually associated with other injuries. Whether associated with other injuries or not, traumatic pancreatic injuries cause significant morbidity and even mortality. Generally, a high-velocity impact or significantly directed blow is required to produce pancreatic injuries [1]. However, in our case, he fell down with his back onto the ground. The force was transmitted through his back directly to the pancreas. In adults, the similar mechanism is described in Chance fracture, which is a flexion injury of the spine. Fortunately, our teenaged patient did not experience any spinal injuries. It might be associated with the pliability of his body, which means much flexible ligaments and joint capsules.

The diagnosis of pancreatic trauma is usually challenging. Elevations in serum amylase and lipase are not reliable to determine pancreatic injuries [2]. Biochemical studies may serve as an indicator of the probable pancreatic injury. Computed tomography, which remains the most powerful Diagnostic modality, demonstrates pancreatic parenchymal injuries and complications such as abscess, fistula, pancrea- titis, and pseudocyst [3]. The findings on CT, which may indicate pancreatic injury, include (1) peripancreatic fluid in the lesser sac, (2) pancreatic hematoma or partial laceration,

(3) diffuse gland enlargement with pancreatitis or focal edema at the site of injury, and (4) thickening of the left

Fig. 1 Ultrasonography showed fluid accumulation (arrows) around the pancrease (P).

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cholangiopancreatography should be considered to determine the treatment plan.

Pancreatic injuries are rare and usually create major diagnostic challenges. Besides focused assessment sonogra- phy in trauma, ultrasonography serves as a practical tool in screening those patients with posttraumatic abdominal pain.

Ming-Tse Tsai MD Jen-Tang Sun MD

Department of Emergency Medicine Far Eastern Memorial Hospital 20060 Taipei County, Taiwan

Fig. 2 Abdominal CT showed pancreatic body tear (arrow) with peripancreatic fluid collection (arrowheads).

anterior renal fascia [2]. Although ultrasonography is widely used in the initial diagnostic assessment of blunt abdominal trauma, it is considered a limited role in the setting of pancreatic injury mostly because the pancreas is in the retroperitoneal area. However, pancreatic injury was first suspected in our case because of the Sonographic findings in the initial assessment. The role of ultrasonography should not be underestimated in this kind of patients because it provides a real-time, noninvasive, and inexpensive means to detect the possible free abdominal fluids or hematoma related to trauma.

Early recognition of disruption of the main pancreatic duct is important because such disruption is the principal cause of delayed complications. Computed tomography findings may suggest disruption of the pancreatic duct, depending on the degree of parenchymal injury [4]. There is some evidence that intravenous contrast-enhanced ultrasonography may be useful in this setting [5]. One study demonstrated that expert ultrasonographers were able to identify up to 80% pancreatic ductal injuries using Ultrasound techniques [6]. If suspicion of major pancreatic ductal injury is present, Endoscopic retrograde cholangiopancreatography or magnetic resonance

Kuang-Chau Tsai MD Department of Emergency Medicine Far Eastern Memorial Hospital 20060 Taipei County, Taiwan

Department of Health Care Administration Oriental Institute of Technology

Taipei, Taiwan

Wan-Ching Lien MD Department of Emergency Medicine National Taiwan University Hospital and

National Taiwan University 10002 Taipei, Taiwan

E-mail address: [email protected] doi:10.1016/j.ajem.2009.09.025

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