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Case Report
 
Complete pancreatic transection associated with splenic injury resulting from blunt trauma
Kumkum Singh, Amit Singh, Shivaji H Vidyarthi, Manish Garg
Department of General Surgery, J.L.N. Medical College, Ajmer, India.


Corresponding Author
: Dr. Kumkum Singh
19 Adarsh Nagar, Ajmer-305001, India.
E-mail: kum_singhajm@yahoo.co.in


History : Received - 06-Nov-2012 Accepted - 11-Jun-2013 Published Online -  14-Jun-2013
DOI : http://dx.doi.org/10.7713/ijms.2013.0026


Abstract

Injury to the pancreas after blunt abdominal trauma is less frequent than that of other solid organs. The clinical presentation can be subtle resulting in delayed treatment with high morbidity and mortality. A seventeen years male presented with pain jaw and abdomen following fall from tree. He was haemodynamically stable with signs of mandible injury. Investigations revealed splenic contusion with moderate haemoperitoneum. Laparotomy revealed complete transection of distal third of body of pancreas. Pancreatic resection with splenectomy was performed. The case is being reported because of the unusual location of complete pancreatic transection resulting from a blunt trauma. A high degree of clinical suspicion with due consideration to the mechanism of injury is key to good outcome in these patients. Major ductal injury is the critical issue in the management and a number of therapeutic choices are available specific to the location of insult.

Keywords : Accidental falls; pancreas; wounds and injuries.

Introduction

Pancreatic injuries usually result from penetrating trauma. Injuries following blunt abdominal trauma are less common and are frequently associated with other visceral organ injuries. Clinical presentation may be misleading in these injuries resulting in delayed diagnosis with resultant high morbidity and mortality. In such cases, a right diagnosis and prompt surgical intervention are necessary to improve the patient’s prognosis. In the majority of patients, pancreatic trauma is associated with major thoraco-abdominal lesions, which are the main factors influencing its clinical evolution in the acute phase. We report a case of complete transection of distal third of body of pancreas, resulting from fall from tree in a young male.

Report of case

A seventeen years male presented with history of fall from tree while cutting wood. The patient presented with pain abdomen and pain in left mandibular region. There were no other significant complaints. On examination, the patient was fully conscious and oriented with a pulse rate of 104 per minute and blood pressure of 100/70 mm Hg. There was pallor. No other external marks of injury were observed anywhere on the body. Abdominal examination revealed minimal tenderness in the epigastric and umbilical region. Skiagrams of chest and abdomen were normal. Ultrasonography revealed moderate free fluid in the pelvis with splenic contusion. In view of cost constraints, CT scan of the abdomen could not be performed. Serum amylase & lipase were within normal limits.  In view of minimal tenderness and haemodynamic stability, conservative management was planned. But next day due to an increase in tenderness and tachycardia (pulse- 126/min), an emergency laparatomy was planned. Immediate exploratory laparotomy revealed total transection of the body of the pancreas at the junction of medial 2/3rd and lateral 1/3rd with major ductal injury (Grade III injury); splenic artery was also found totally transected and lumen of artery was blocked due to clot & spasm (Figure 1). Spleen was also lacerated near hilum. There were no other associated visceral injuries. Distal pancreatectomy with splenectomy was performed. Surgery was supplemented with medical therapy in the form of antibiotics (ceftriaxone, amikacin and metronidazole), analgesics and H2-blockers for stress ulcer prophylaxis. Enteral nutrition was started on the fifth post-operative day. The patient made an uneventful recovery and was discharged on 11th post-operative day.



Discussion

Pancreatic injuries are uncommon injuries constituting less than 10% of all abdominal injuries [1]. The present case is of particular significance for the presence of transection of the distal third of body of pancreas with major duct injury, without any violent trauma or penetrating injury. Most of the pancreatic injuries (70-75%) are caused by penetrating injuries and are associated with injuries to other viscera like spleen, duodenum, liver, kidney, inferior vena cava, aorta or portal vein. Pancreatic injuries in blunt abdominal trauma are caused due to crushing of the pancreas between the vertebral column and another surface [1]. These represent a major diagnostic challenge. Retroperitoneal location of pancreas combined with reduced secretion and inactivity of pancreatic enzymes following injury may account for paucity of early physical signs [2]. This carries significant morbidity and mortality due to delay in diagnosis and treatment [3]. Diagnosis requires high degree of suspicion [3]. The male to female ratio has been reported to be 8.4:1 and average age as 34.98 years in one series [4]. Usually the initial complaints are vague and nonspecific. The patient presents with mid-epigastric or back-pain 6 to 24 hours after the injury. Physical signs include mid-epigastric tenderness in the early and frank peritonitis in late presentation. Serum hyperamylasemia is neither sensitive nor specific [1]. Ultrasonography is moderately sensitive in expert hands with a reported sensitivity of 44% [5]. Diagnosis is usually made by abdominal CT scan which has a reported sensitivity up to 68% [6]. Complete or more than 50% pancreatic transection on CT is usually associated with major ductal injury which mandates early surgery. Endoscopic retrograde cholangiopancreatography (ERCP)/ magnetic resonance cholangiopancreatography (MRCP) can be used to diagnose pancreatic ductal injuries in haemodynamically stable patients.  

Pancreatic injuries are graded by pancreatic organ injury scale (Table 1)



Treatment of grade I and II injuries includes either conservative or wide drainage. Grade III injuries are best treated with distal pancreatectomy with or without splenectomy. A variety of procedures are described for grade IV and V injuries ranging from Roux en Y pancreatico-jejunostomy, pancreatico-gastrostomy, pyloric exclusion, duodenal diverticulization and pancreatico-duodenectomy [7]. Recently stenting of the injured pancreatic duct with endoscopic retrograde pancreatography (ERP) has been shown to be effective [8].

Complications after pancreatic injuries include pancreatic fistula, pancreatic or intraabdominal abscess, pancreatitis and pseudocyst. These complications may present at variable periods following pancreatic injuries ranging from days to years. Majority of complications related to pancreatic injuries are self limiting or treatable but development of sepsis and multisystem organ failure results in most of the late deaths.

Key Points

Morbidity and mortality from pancreatic injuries are high. 
Blunt pancreatic trauma continues to pose significant diagnostic and therapeutic challenges. 
As clinical presentation is usually subtle, a high index of suspicion is required. 
An optimal strategy consisting of CT abdomen and serial serum amylase & lipase estimation supplemented with ERP should be planned to make timely diagnosis. 
The optimal management of pancreatic injury once a diagnosis has been made is also not well established. Non-operative management, suture and repair, resection with non-drainage or drainage of injury have all been utilised with varying degrees of success.

References 

1. Cirillo RL Jr, Koniaris LG. Detecting blunt pancreatic injuries. J Gastrointest Surg 2002;6:587-98. 
2. Horst HM, Bivins BA. Pancreatic transection: a concept of evolving injury. Arch Surg 1989;124:1093-5. 
3. Chrysos E, Athanasakis E, Xynos E. Pancreatic trauma in the adult: current knowledge in diagnosis and management. Pancreatology 2002;2:365-78.  
4. Mukhopadhyay M. Intestinal injury from blunt abdominal trauma: a study of 47 cases. Oman Med J 2009;24:256-9. 
5. Sato M, Yoshii H. Reevaluation of ultrasonography for solid organ injury in blunt abdominal trauma. J Ultrasound Med 2004;23:1583-96. 
6. Ilahi O, Bochicchio GV, Scalea TM. Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study. Am Surg 2002;68:704-8. 
7. Lin BC, Chen RJ, Fang JF, Hsu YP, Kao YC, Kao JL. Management of blunt major pancreatic injury. J Trauma 2004;56:774-8. 
8. Huckfeldt R, Agee C, Nichols WK, Barthel J. Nonoperative treatment of traumatic pancreatic duct disruption using an endoscopically placed stent. J Trauma 1996;41:143-4. 
9. Jain S, Telang P, Joshi MA, Prabhakar S. Isolated pancreatic injury following blunt abdominal  trauma in a child. Indian J Crit Care Med 2007;11:96-8. 

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