Teaching Case

A 28-year-old male patient with no past medical history presents to the emergency department with abdominal pain after being kicked in the epigastrium while playing soccer. In the initial blood tests transaminase elevation was documented. Due to the suspicion of liver injury, an imaging study was requested.

In the abdominal CT a hypodense focus is observed between the head and the body of the pancreas, that doesn't enhance with contrast. There is peri-duodenal and peri-pancreatic fluid associated (Fig.1).

Magnetic resonance cholangiopancreatography (MRCP) was performed to evaluate the status of the main pancreatic duct. The common hepatic duct and the common bile duct are clearly visualised, while the integrity of the pancreatic duct cannot be determined (Fig.2a).

In the T1-weighted images after the gadolinium chelate administration, a complete laceration between the head and body of the pancreas is observed (Fig.2b), with a significant increase of the free intra-abdominal fluid in the T2-weighted images (Fig. 2c).

Pancreatic duct rupture was confirmed with an endoscopic retrograde cholangiopancreatography (ERCP). Images show contrast leak after its injection through the proximal pancreatic duct (Fig.3).

Pancreatic trauma is a rare entity, it occurs in less than 10% of all blunt traumatic abdominal injuries and is usually secondary to direct impacts [1]. The injury mechanism is due to the anteroposterior compression of the pancreas against the spine. The body of the pancreas is the most frequently affected portion in the majority of cases [1, 2].

At the beginning symptoms can be nonspecific and blood tests can be normal. A typical clinical triad in pancreatic trauma has been described, it consists of upper abdominal pain, leukocytosis and elevated serum amylase [2, 3], all of the three were present in our patient.

This pathology is associated with high morbidity and mortality due to the development of numerous complications such as pancreatic fistulas, abscesses, haemorrhage, pancreatitis, pseudo-cysts and endocrine insufficiency [1].

The most used classification to evaluate the degree of severity of pancreatic trauma is the one proposed by the American Association for the Surgery of Trauma (AAST), which classifies pancreatic trauma into each of 5 degrees [3, 4]. The main factors affecting the morbidity and mortality rate of patients are the location of the lesion (proximal lesions are more serious and they are usually associated with injury of other structures: vascular, biliary, portal, mesenteric, etc.) and the compromise of the main pancreatic duct [2, 3].

The treatment of choice is decided upon according to the severity of the pancreatic injury, principally determined by the involvement of the pancreatic duct [3, 4]; if it is not injured, management will be conservative, with drainage of possible collections. In case of pancreatic duct injury, treatment willl mainly be surgical and the technique will be chosen depending on the lesion, from focal distal pancreatectomy to pancreatoduodenectomy. One important conservative method for treating the ruptured duct is endoscopic stenting to prevent pancreatic juice leakage [3, 4].

In summary, pancreatic injuries due to blunt trauma are rare and may go unnoticed at first. Morbidity and mortality rates are high if timely diagnosis and treatment are not established. That is why a high suspicion is essential for these patients in order to perform adequate imaging techniques and offer the best treatment.

Our patient's evolution was not favourable with the development of infected necrotic collections, peripancreatic fistulas and necrosis of the pancreas and duodenum, which required multiple surgical interventions and per-cutaneous drainage.

Written informed patient consent for publication has been obtained.