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Case report: Ultrasound demonstration of traumatic fracture of the pancreas with pancreatic duct disruption
Clinical Radiology (1993) 47, 434-435
Case Report: Ultrasound Demonstration of Traumatic Fracture of the Pancreas With Pancreatic Duct Disruption R. G O T H I , N. C. BOSE* and N. K U M A R t
Dr Diwan Chand Aggarwal Imaging Research Centre, New Delhi, *Safdarjang Hospital, New Delhi and ~(GB Pant Hospital, New Delhi, India Fracture of the pancreas is a rare injury caused by blunt abdominal trauma. Abdominal CT is probably the best modality for the detection of this uncommon injury. Ultrasonography is excellent for demonstrating an accompanying pseudocyst, but it is otherwise considered less effective than CT in the evaluation of pancreatic trauma. We report a case where we were able to demonstrate a fracture through the body of the pancreas along with disruption of the pancreatic duct, using a conventional ultrasound scanner.
Gothi, R., Bose, N.C. & Kumar, N. (1993). Clinical Radiology 47, 434-435. Case Report: Ultrasound Demonstration of Traumatic Fracture of the Pancreas With Pancreatic Duct Disruption
CASE REPORT A 20-year-old male patient was admitted with a history of having fallen down the stairs, 10 days previously. On examination, there was a large tender lump in the epigastrium. A clinical diagnosis of post-traumatic pancreatitis with pseudopancreatic cyst was made. The biochemical analysis showed serum amylase of 120 iu/1 (N 50 140 U/l). The amylase content of the pseudocyst was 1200 IU/1. The haemogram was within normal limits. An ultrasound examination of the upper abdomen was performed using a 3 M H z Philips S D R 1550 sector scanner. A large pseudocyst was seen in the region o f the lesser sac. The pancreas could be well visualized through it on transverse scanning. The head of the pancreas was normal. Just beyond the neck, in the region of the body, a hypoechoic plane was seen traversing the pancreas, dividing it into two (Fig. la). A small tubular structure with echogenic walls was visualized at this site, swaying in the fluid collection. This was thought to be the severed tip of the distal pancreatic duct. It was easily identifiable in other planes also (Fig. lb), unchanging in appearance. A n ultrasound diagnosis of traumatic fracture of the pancreas with disruption of the pancreatic duct in the region of the body, was made. A few days later the patient underwent an E R C P examination (Fig.
lc). The C B D was found stretched along the pseudocyst. The proximal length of the pancreatic duct in the head region was well opacified and normal in calibre. Beyond this, it was abruptly cut off at a point which corresponded with the sonographically-demonstrated site. The distal part of the duct did not opacify. An E R C P diagnosis of transection o f the main pancreatic duct in the midbody was made. There was no evidence of extravasation of contrast from the site of duct disruption, presumably because the duct had sealed off by the time the E R C P was undertaken. The patient subsequently underwent an exploratory laparotomy. There was a large well-encapsulated pseudocyst with a thick fibrous wall. The stomach and d u o d e n u m were displaced and stretched but were otherwise normal. The spleen and liver were also normal. No attempt was made to expose the pancreas as the large pseudocyst was completely covering it. A cystogastrostomy was performed and the patient was kept under observation. The post-operative recovery was uneventful. The patient's condition was satisfactory at the time o f discharge with no recurrence of the pseudocyst.
Correspondence to: Dr R. Gothi, Consultant Radiologist, Diwan Chand Aggarwal Imaging Research Centre, I0 B. Kasturba Gandhi Marg, New Delhi 1 I0001, India.
DISCUSSION Traumatic injury of the pancreas including a fracture is an uncommon event. The pancreas is injured in less than 2% patients with trauma, of which only one third of the injuries are blunt trauma while the remainder are penetrating injuries [1]. The pre-operative diagnosis of pancreatic injury has now become possible with the availability of CT [2] and ultrasound [3]. Ultrasonography has been considered less reliable in the acutely-injured patient with pancreatic trauma [4] despite the fact that several sonographic findings have been described by various authors [3,5-7]. These findings include demonstration of a focal hypoechoic mass in the pancreas, diffuse enlargement with hypoechogenicity, pseudocyst formation, presence of fluid in the peritoneal cavity or in the retroperitoneum. Recently, sonography has also been reported to have demonstrated a fracture through the body of the pancreas [5]. We were able to visualize a fracture of the pancreas on sonographic examination, and were also able to show ductal disruption at the fracture site. The characteristic sonographic features of the pancreatic duct allow confident differentiation of this structure from a laceration extending from the pancreatic body. While a normal duct is readily identified in 82-86% of patients in the midbody [7], visualization is often not as good in traumatic pancreatic pathology. In our case, however, demonstration of the duct was facilitated not only by its location in the midbody but also by the presence o f a pseudocyst as an acoustic window. CT is more effective than ultrasound in demonstrating a fracture [8]. However, unless thin sections are obtained or the duct is dilated, a disrupted duct with a normal calibre may be difficult to identify on CT. As seen in our case, ERCP is undoubtedly the best modality to visualize the disrupted pancreatic duct and has been used for the diagnosis of major ductal disruption [9]. It has, however, not been found to be necessary in the management of pancreatic trauma, because treatment is generally based on clinical and CT findings [10].
435
TRAUMATIC FRACTURE OF THE PANCREAS
(a)
(b)
(c)
Fig. 1 - (a) Transverse scan through the body of the pancreas, showing the fracture (F) with disruption of the duct (PD). (b) Midline longitudinal scan of the pancreas (P), through the fracture (F). The pseudocyst collection (COLL) is seen superiorly. The duct (PD) is visualized end-on. Note that its tubular appearance, bordered by echogenic walls, has remained unchanged in this scan plane also. (c) Radiograph of the ERCP shows a segment of the pancreatic duct (P) in the head with abrupt cut off distally. The distal duct is not visualized. The CBD (B) is seen sweeping along the pseudocyst.
In conclusion, with conventional sonography, it is possible not only to demonstrate a pancreatic fracture but also to visualize disruption of the main pancreatic duct. Acknowledgements. We are grateful to Dr P. C. Rai, Medical Superintendent, Safdarjang Hospital, New Delhi, for permitting us to go through the hospital records. Thanks are also due to Dr Sudershan Aggarwal o f Dr Diwan Chand Aggarwal Imaging Research Centre for allowing us to use his magnificent radiology library. REFERENCES 1 Yeo CJ, Cameron JL. The pancreas. In: Sabiston DC, ed. Textbook o f surgery. The biologic basis o f modern surgical practice, 14th ed. Philadelphia: WB Saunders Co, 1991:1076-1107. 2 Dodds W J, Taylor A J, Erickson SJ, Lawson TL. Traumatic fracture of the pancreas: CT characteristics. Journal of Computer Assisted Tomography 1990; 14(3):375-378. 3 Mittelstaedt CA. The pancreas. In: Abdominal ultrasound. New York: Churchill Livingstone, 1987:163-220.
4 Jeffrey RB. The pancreas. In: CT and sonography of the acute abdomen. New York: Raven Press, 1989:111-148. 5 Steenbergen WV, Samain H, Pouillon M, Roost WV, Marchal G, Baert A et al. Transection of the pancreas demonstrated by ultrasound and computed tomography. Gastrointestinal Radiology 1987;12:128-130. 6 Kaude JV, Mclnnis AN. Pancreatic ultrasound following blunt abdominal trauma. Gastrointestinal Radiology 1982;7:53 56. 7 Sarti DA. Ultrasonography of the pancreas. In: Sarti DA, ed. Diagnostic ultrasound text and cases, 2nd ed. Chicago: Yearbook Medical Publishers, 1987:214-283. 8 Federle MP, Goldberg HI, Kaiser JA, Moss AA, Jeffrey RB Jr, Mall JC. Evaluation of abdominal trauma by computed tomography. Radiology 1981;138:637 644. 9 Whitwell AE, Gomez GA, Byers P, Kreis D J, Manten H, Casillas VJ. Blunt pancreatic trauma. Prospective evaluation of early endoscopic retrograde pancreatography. Southern Medical Journal 1989;82(5): 586-59 I. I0 Jordan GL. Injury to the pancreas and duodenum. In: Moore EE, Mattox KL & Feliciano DV, eds. Trauma, 2nd ed. Appleton and Lange, 1991:Ch. 32, 499-520.
Case Report: Ultrasound Demonstration of Traumatic Fracture of the Pancreas With Pancreatic Duct Disruption R. G O T H I , N. C. BOSE* and N. K U M A R t
Dr Diwan Chand Aggarwal Imaging Research Centre, New Delhi, *Safdarjang Hospital, New Delhi and ~(GB Pant Hospital, New Delhi, India Fracture of the pancreas is a rare injury caused by blunt abdominal trauma. Abdominal CT is probably the best modality for the detection of this uncommon injury. Ultrasonography is excellent for demonstrating an accompanying pseudocyst, but it is otherwise considered less effective than CT in the evaluation of pancreatic trauma. We report a case where we were able to demonstrate a fracture through the body of the pancreas along with disruption of the pancreatic duct, using a conventional ultrasound scanner.
Gothi, R., Bose, N.C. & Kumar, N. (1993). Clinical Radiology 47, 434-435. Case Report: Ultrasound Demonstration of Traumatic Fracture of the Pancreas With Pancreatic Duct Disruption
CASE REPORT A 20-year-old male patient was admitted with a history of having fallen down the stairs, 10 days previously. On examination, there was a large tender lump in the epigastrium. A clinical diagnosis of post-traumatic pancreatitis with pseudopancreatic cyst was made. The biochemical analysis showed serum amylase of 120 iu/1 (N 50 140 U/l). The amylase content of the pseudocyst was 1200 IU/1. The haemogram was within normal limits. An ultrasound examination of the upper abdomen was performed using a 3 M H z Philips S D R 1550 sector scanner. A large pseudocyst was seen in the region o f the lesser sac. The pancreas could be well visualized through it on transverse scanning. The head of the pancreas was normal. Just beyond the neck, in the region of the body, a hypoechoic plane was seen traversing the pancreas, dividing it into two (Fig. la). A small tubular structure with echogenic walls was visualized at this site, swaying in the fluid collection. This was thought to be the severed tip of the distal pancreatic duct. It was easily identifiable in other planes also (Fig. lb), unchanging in appearance. A n ultrasound diagnosis of traumatic fracture of the pancreas with disruption of the pancreatic duct in the region of the body, was made. A few days later the patient underwent an E R C P examination (Fig.
lc). The C B D was found stretched along the pseudocyst. The proximal length of the pancreatic duct in the head region was well opacified and normal in calibre. Beyond this, it was abruptly cut off at a point which corresponded with the sonographically-demonstrated site. The distal part of the duct did not opacify. An E R C P diagnosis of transection o f the main pancreatic duct in the midbody was made. There was no evidence of extravasation of contrast from the site of duct disruption, presumably because the duct had sealed off by the time the E R C P was undertaken. The patient subsequently underwent an exploratory laparotomy. There was a large well-encapsulated pseudocyst with a thick fibrous wall. The stomach and d u o d e n u m were displaced and stretched but were otherwise normal. The spleen and liver were also normal. No attempt was made to expose the pancreas as the large pseudocyst was completely covering it. A cystogastrostomy was performed and the patient was kept under observation. The post-operative recovery was uneventful. The patient's condition was satisfactory at the time o f discharge with no recurrence of the pseudocyst.
Correspondence to: Dr R. Gothi, Consultant Radiologist, Diwan Chand Aggarwal Imaging Research Centre, I0 B. Kasturba Gandhi Marg, New Delhi 1 I0001, India.
DISCUSSION Traumatic injury of the pancreas including a fracture is an uncommon event. The pancreas is injured in less than 2% patients with trauma, of which only one third of the injuries are blunt trauma while the remainder are penetrating injuries [1]. The pre-operative diagnosis of pancreatic injury has now become possible with the availability of CT [2] and ultrasound [3]. Ultrasonography has been considered less reliable in the acutely-injured patient with pancreatic trauma [4] despite the fact that several sonographic findings have been described by various authors [3,5-7]. These findings include demonstration of a focal hypoechoic mass in the pancreas, diffuse enlargement with hypoechogenicity, pseudocyst formation, presence of fluid in the peritoneal cavity or in the retroperitoneum. Recently, sonography has also been reported to have demonstrated a fracture through the body of the pancreas [5]. We were able to visualize a fracture of the pancreas on sonographic examination, and were also able to show ductal disruption at the fracture site. The characteristic sonographic features of the pancreatic duct allow confident differentiation of this structure from a laceration extending from the pancreatic body. While a normal duct is readily identified in 82-86% of patients in the midbody [7], visualization is often not as good in traumatic pancreatic pathology. In our case, however, demonstration of the duct was facilitated not only by its location in the midbody but also by the presence o f a pseudocyst as an acoustic window. CT is more effective than ultrasound in demonstrating a fracture [8]. However, unless thin sections are obtained or the duct is dilated, a disrupted duct with a normal calibre may be difficult to identify on CT. As seen in our case, ERCP is undoubtedly the best modality to visualize the disrupted pancreatic duct and has been used for the diagnosis of major ductal disruption [9]. It has, however, not been found to be necessary in the management of pancreatic trauma, because treatment is generally based on clinical and CT findings [10].
435
TRAUMATIC FRACTURE OF THE PANCREAS
(a)
(b)
(c)
Fig. 1 - (a) Transverse scan through the body of the pancreas, showing the fracture (F) with disruption of the duct (PD). (b) Midline longitudinal scan of the pancreas (P), through the fracture (F). The pseudocyst collection (COLL) is seen superiorly. The duct (PD) is visualized end-on. Note that its tubular appearance, bordered by echogenic walls, has remained unchanged in this scan plane also. (c) Radiograph of the ERCP shows a segment of the pancreatic duct (P) in the head with abrupt cut off distally. The distal duct is not visualized. The CBD (B) is seen sweeping along the pseudocyst.
In conclusion, with conventional sonography, it is possible not only to demonstrate a pancreatic fracture but also to visualize disruption of the main pancreatic duct. Acknowledgements. We are grateful to Dr P. C. Rai, Medical Superintendent, Safdarjang Hospital, New Delhi, for permitting us to go through the hospital records. Thanks are also due to Dr Sudershan Aggarwal o f Dr Diwan Chand Aggarwal Imaging Research Centre for allowing us to use his magnificent radiology library. REFERENCES 1 Yeo CJ, Cameron JL. The pancreas. In: Sabiston DC, ed. Textbook o f surgery. The biologic basis o f modern surgical practice, 14th ed. Philadelphia: WB Saunders Co, 1991:1076-1107. 2 Dodds W J, Taylor A J, Erickson SJ, Lawson TL. Traumatic fracture of the pancreas: CT characteristics. Journal of Computer Assisted Tomography 1990; 14(3):375-378. 3 Mittelstaedt CA. The pancreas. In: Abdominal ultrasound. New York: Churchill Livingstone, 1987:163-220.
4 Jeffrey RB. The pancreas. In: CT and sonography of the acute abdomen. New York: Raven Press, 1989:111-148. 5 Steenbergen WV, Samain H, Pouillon M, Roost WV, Marchal G, Baert A et al. Transection of the pancreas demonstrated by ultrasound and computed tomography. Gastrointestinal Radiology 1987;12:128-130. 6 Kaude JV, Mclnnis AN. Pancreatic ultrasound following blunt abdominal trauma. Gastrointestinal Radiology 1982;7:53 56. 7 Sarti DA. Ultrasonography of the pancreas. In: Sarti DA, ed. Diagnostic ultrasound text and cases, 2nd ed. Chicago: Yearbook Medical Publishers, 1987:214-283. 8 Federle MP, Goldberg HI, Kaiser JA, Moss AA, Jeffrey RB Jr, Mall JC. Evaluation of abdominal trauma by computed tomography. Radiology 1981;138:637 644. 9 Whitwell AE, Gomez GA, Byers P, Kreis D J, Manten H, Casillas VJ. Blunt pancreatic trauma. Prospective evaluation of early endoscopic retrograde pancreatography. Southern Medical Journal 1989;82(5): 586-59 I. I0 Jordan GL. Injury to the pancreas and duodenum. In: Moore EE, Mattox KL & Feliciano DV, eds. Trauma, 2nd ed. Appleton and Lange, 1991:Ch. 32, 499-520.