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Identification of traumatic rupture of the pancreatic duct by endoscopic retrograde pancreatography
the most characteristic macroscopic lesion of early amebic colitis is the presence of a smooth, small, nodular area above the level of the mucosa. This is often surrounded by a halo of congestion or hemorrhage and could easily be mistaken for enlarged lymphoid follicles. In Castro's study, the size of the lesions varied from 0.5 to 2.5 cm or larger. These appeared to be actually very small ulcers with raised borders and were surrounded by congested or hemorrhagic mucosa. The intervening mucosa between the ulcers was normal in most instances. One should be as certain as possible before diagnosing a patient's disease as ulcerative colitis or Crohn's disease. Corticosteroids often are an integral part of the treatment regimen in these patients. However, in addition to the well known side effects and compl ications caused by these drugs, they may be lethal if used in acute invasive amebiasis.'
Identification of traumatic rupture of the pancreatic duct by endoscopic retrograde pancreatography
Injuries to the pancreas are rare and are usually the result of blunt trauma when the organ is compressed against the spinal column or severed against its edge. According to Schwemmle,'° it is to be expected that the pancreas will be involved in about 10% of all cases of injury to the upper abdomen. It may be difficult to recognize isolated injury to the pancreas, inasmuch as often only slight abdominal pain occurs. letton et al. B ascribe this observation to: (1) the retroperitoneal position of the organ, (2) the absence of enzyme-active activating substances in the case of localized injuries, and (3) the reduced secretion following substantial injury. The main diagnostic problem, when dealing with injuries to the pancreas, is determination of the extent and the exact localization of the injury; these factors essentially influence the therapeutic procedure. Increased amylase activity in serum, urine, and peritoneal secretion, as well as enlargement of the organ as shown by ultrasonography, usually allow on Iy a suspicion of pancreatic injury. Even during operation, it is not always possible to distinguish precisely a contusion and a partial or complete duct rupture accompanied by destruction of the organ. This is especially true in patients with old injuries to the pancreas. Bach,. therefore, recommends in doubtful cases that the pancreatic duct be outlined during surgery, either by means of catherization of the duodenal papilla or of the severed duct after resection of the pancreatic tail. Precise examination of the pancreatic duct is made by instilling contrast medium into the duct. The main pancreatic duct also may be radiographically examined by endoscopic retrograde pancreatography (ERP) immediately before surgical intervention. "Reprint requests: Provo Doz. Dr. med. D. Belohlavek, Universitat Ulm, Department Innere Medizin, Sektion Gastroenterologie, Steinhiivelstr. 9, 7900 Ulm/Donau, Germany. VOLUME 24, NO.5, 1978
REFERENCES 1. KANAN I SR, KNIGHT R: Relapsing amoebic colitis of 12 years' standing exacerbated by corticosteroids. Br Me
Gastrointestinal Disease; Pathophysiology, Diagnosis, Management. Philadelphia, Saunders, 1973, p. 1389 6. KAGAN IG: Serologic diagnosis of parasitic diseases. N Engl J Me
1970 7. CORRAL E, STOOPEN M, URIZAR A, VERDIN F: Observation de las lesiones amibionas par medio del colonoscopio. Arch Invest Med (Mexico) 4:Suppl 1:197,1973 8. RAMIREZ-DEGOLLADO L TANIMOTO-WEKI M: La colonoscopia en las amibiasis invasora: Arch Invest Med (Mexico) 5:Suppl 2:519, 1974 9. CASTRO HF: Anatomic and pathological findings in amebiasis; report of 320 cases. In "Amebiasis in Man," Padilla CM, Padilla CA, eds., p. 48; Springfield, Illinois; Chas C Thomas, 1974
D. Belohlavek, MD* P. Merkle, MD M. Probst, MD Gastroenterology Section Department of Internal Medicine and General Surgery Division University Clinic University of Ulm Ulm, Germany In 2 patients who had suffered severe injuries to the upper abdomen, we delineated the pancreatic duct by ERP and were able in both cases to prove clearly the presence of a rupture of the pancreatic duct. To our knowledge, the use of ERP to define isolated trauma to the pancreas has not been previously documented. CASE REPORTS Case 1. A 17-year-old lad struck his stomach against a sharp corner when jumping over a bench on 6 March 1974, causing diffuse abdominal pain. Because of blunt injury to the abdomen, he was admitted to the hospital, where the urine amylase was found to be increased, and treatment for suspected acute pancreatitis was initiated. Following early improvement, the pain grew worse. On 2 April 1974, he was admitted to our hospital looking haggard and ill. The abdominal wall was taut and hard, and a tender resistance was felt in the right upper abdomen. Intestinal sounds were reduced. The hemoglobin was 11 g and the hematocrit was 32%; amylase activity in the serum and urine was normal. The serum amylase later rose to 900 U/1. ERP was performed on 22 April 1974. After filling the pancreatic duct with contrast, a stenosis of the pancreatic duct at the point of j unction of the head and body was evidenced by narrowing in the column and an extraductal collection (Figure 1). The findings were interpreted as a rupture of the pancreatic duct with traumatic pseudocyst. Subsequent laparotomy revealed a pseudocyst at the junction of the head and body of the pancreas. The radiographically demonstrated point of rupture and cyst formation were found. The cyst was opened and drained by means of a Roux-en-y anastomosis, and the patient's postoperative course was without complication. Case 2. During a soccer game on 13 March 1977, an 18-year-old lad suffered a blow from an opponent's knee to the middle of the abdomen somewhat to the left of the
255
Figure 1. ERP showing stenosis and rupture of the proximal pancreatic duct with extravasation of contrast medium into a traumatic pseudocyst. Note the filling of the duct beyond the point of rupture.
Figure 2. ERP showing extravasation from the distal pancreatic duct with contrast medium trickling down to the left of the lumbar vertebrae.
umbilicus. Vomiting occurred repeatedly. On admission the same day to an out-of-town hospital, he was noted to have severe pains in the left upper abdomen, slight muscular tautness, and normal intestinal peristalsis. His hemoglobin was 16.9 g, hematocrit 49%, WBC 19,000, serum amylase 8,200 U/I, urine amylase 24,000 U/I, calcium 2.4 mEq/1. On 16 March 1977 he was transferred to our hospital. Examination showed localized abdominal tenderness and muscular wall resistance to the left of the umbilicus. Intestinal peristalsis was active. On 17 March 1977 ERP was carried out. Following opacification of the pancreatic duct, the contrast medium flowed from the pancreatic duct close to the left edge of the spinal column. This was interpreted as extravasation due to rupture of the duct (Figure 2). Laparotomy was carried out on the same day. At operation, focal areas of calcified fat necrosis in the upper abdomen gave evidence of pancreatitis. After opening the lesser sac, the pancreas was seen to be jelly-like and covered with calcium flecks. Rupture was not grossly identifiable. The distal portion of the pancreas was resected without complication. The operative specimen showed subcapsular pancreatic duct rupture.
also, orientation with regard to the anatomical situation was not easy, even though before operation the conditions were made clear by ERP. In cases of acute injury to the upper abdomen, when the nature of the injury and the clinical and laboratory findings suggest pancreatic involvement, ERP should be carried out to obtain evidence of a break in continuity ofthe pancreatic duct. If one can anticipate the need for operation whi Ie the examination is being carried out, severe complications can be largely avoided by prompt surgical intervention. Our success in the identification of rupture of the pancreas, immediately after injury or several weeks later, strengthens our conviction that there should be a greater readiness to use the so-called emergency ERP.9 Identification of rupture of the duct by ERP simplifies the decision as to the necessity of surgical intervention, avoids superfluous exploratory laparotomies, and helps to prevent severe complications such as fistulas, cysts, hematomas, and abscesses.
DISCUSSION A consequence of acute injury to the pancreas can be rupture of the pancreatic duct with destruction of periductal tissue. When there is loss of continuity of the pancreatic duct, contrast ~edium instilled enters the periductal tissue,providing retrograde evidence ofthe existence of an injury to the pancreatic duct. In both of our cases, we were able to trace the duct as far as the periphery in spite of the injury. The risk of provoking acute pancreatitis, which has an occurrence rate of approximately 1 % with ERps,w can generally,be reduced by careful instillation of the contrast medium. Apart from this, the risk of pancreatitis is largely removed if an operation is immediately carried out. The surgical procedure is simplified by exact localization of apancreatic duct rupture. Bach 4 reports that of 6 patients with complete severance of the organ, the rupture was overlooked in 2 as a result of a pronounced chronic inflammation in the pancreas and in the surround ing tissue. Anderson 2 also reports cases where pancreatic injuries with rupture of the duct were overlooked during initial exploration because evaluation was hampered by extensive hematoma formation. In our cases
256
REFERENCES 1. ANANE-SEFAH ), NORTON LW, EISEMAN B: Operative choice and techni-
que following pancreatic injury. Arch Surg 110:161, 1975 2. ANDERSON CB, CONNORS JP, MEJIA DC, WISE L: Drainage methods in the
treatment of pancreatic injuries. Surg Gynecol Obstet 138:587. 1974 3. ANDERSON CB, WEISZ D, RODGER MR, TUCKER GL: Combined pan-
creaticoduodenaltrauma. Am J Surg 125:530, 1973 4. BACH RD, FREY CF: diagnosis and treatment of pancreatic trauma. Am
J
Surg 121:20, 1971 5. BELOHLAVEK D, KOCH H, ROSCH W, SCHAFFNER 0, MAEDER HU, FLORY L CLASSEN M, DEMLING L: Five years experience in endoscopic retrograde
cholangiopancreaticography (ERCP). Endoscopy 8: 115, 1976 FEUSEL H: Chirurgie der traumatischen Pankreaslasion. Notfallmedizin 3: 150, 1977 7. JONES RC, SHIRES GT: Pancreatic trauma. Arch Surg 102:424, 1971 8. LETTON AH, WILSON JP: Traumatic severance of pancreas treated by Roux-y-anastomosis. Surg Gynecol Obstet 109:473, 1959
6. FILLER D, SCHWEMMLE K, MUHRER KH,
9. MIEDERER WE, STADELMANN
10.
11.
12. 13. 14.
0,
LOFFLERA, WOBSTER E, KOITSCHWITZ K:
Die endoskopische retrograde Cholangio-Pankreatikographie (ERCP): Indikation, Methode, Wertigkeit und Risiko. Leber Magen Darm 4: 187, 1974 NEBEL OT, SILVIS SE, ROGERS G, SUGAWA C, MANDELSTAM P: Complications associated with endoscopic retrograde cholangiopancreaticography. Gastrointestinal Endoscopy 22:34, 1975 SAFRANY L, SCHON LEBEN K, WITTRIN G, RODIGER E: Die Hamobilie.Leber Magen Darm 5:229,1975 SCHWEMMLE K, GRABNER W, PHILLIP), BOTTICHER R: Die operative Therapie der Pankreasverletzungen. Bruns' Beitr klin Chir 220:675,1973 SCHWEMMLE K, SELBACH KD: Perforierende Bauchverletzungen SofortmaBnahmen. Notfallmedizin 2:732, 1976 WERSCHKY LR, JORDAN GL: Surgical management of traumatic injuries to the pancreas. Am Surg 116:768, 1968 GASTROINTESTINAL ENDOSCOPY
Identification of traumatic rupture of the pancreatic duct by endoscopic retrograde pancreatography
Injuries to the pancreas are rare and are usually the result of blunt trauma when the organ is compressed against the spinal column or severed against its edge. According to Schwemmle,'° it is to be expected that the pancreas will be involved in about 10% of all cases of injury to the upper abdomen. It may be difficult to recognize isolated injury to the pancreas, inasmuch as often only slight abdominal pain occurs. letton et al. B ascribe this observation to: (1) the retroperitoneal position of the organ, (2) the absence of enzyme-active activating substances in the case of localized injuries, and (3) the reduced secretion following substantial injury. The main diagnostic problem, when dealing with injuries to the pancreas, is determination of the extent and the exact localization of the injury; these factors essentially influence the therapeutic procedure. Increased amylase activity in serum, urine, and peritoneal secretion, as well as enlargement of the organ as shown by ultrasonography, usually allow on Iy a suspicion of pancreatic injury. Even during operation, it is not always possible to distinguish precisely a contusion and a partial or complete duct rupture accompanied by destruction of the organ. This is especially true in patients with old injuries to the pancreas. Bach,. therefore, recommends in doubtful cases that the pancreatic duct be outlined during surgery, either by means of catherization of the duodenal papilla or of the severed duct after resection of the pancreatic tail. Precise examination of the pancreatic duct is made by instilling contrast medium into the duct. The main pancreatic duct also may be radiographically examined by endoscopic retrograde pancreatography (ERP) immediately before surgical intervention. "Reprint requests: Provo Doz. Dr. med. D. Belohlavek, Universitat Ulm, Department Innere Medizin, Sektion Gastroenterologie, Steinhiivelstr. 9, 7900 Ulm/Donau, Germany. VOLUME 24, NO.5, 1978
REFERENCES 1. KANAN I SR, KNIGHT R: Relapsing amoebic colitis of 12 years' standing exacerbated by corticosteroids. Br Me
Gastrointestinal Disease; Pathophysiology, Diagnosis, Management. Philadelphia, Saunders, 1973, p. 1389 6. KAGAN IG: Serologic diagnosis of parasitic diseases. N Engl J Me
1970 7. CORRAL E, STOOPEN M, URIZAR A, VERDIN F: Observation de las lesiones amibionas par medio del colonoscopio. Arch Invest Med (Mexico) 4:Suppl 1:197,1973 8. RAMIREZ-DEGOLLADO L TANIMOTO-WEKI M: La colonoscopia en las amibiasis invasora: Arch Invest Med (Mexico) 5:Suppl 2:519, 1974 9. CASTRO HF: Anatomic and pathological findings in amebiasis; report of 320 cases. In "Amebiasis in Man," Padilla CM, Padilla CA, eds., p. 48; Springfield, Illinois; Chas C Thomas, 1974
D. Belohlavek, MD* P. Merkle, MD M. Probst, MD Gastroenterology Section Department of Internal Medicine and General Surgery Division University Clinic University of Ulm Ulm, Germany In 2 patients who had suffered severe injuries to the upper abdomen, we delineated the pancreatic duct by ERP and were able in both cases to prove clearly the presence of a rupture of the pancreatic duct. To our knowledge, the use of ERP to define isolated trauma to the pancreas has not been previously documented. CASE REPORTS Case 1. A 17-year-old lad struck his stomach against a sharp corner when jumping over a bench on 6 March 1974, causing diffuse abdominal pain. Because of blunt injury to the abdomen, he was admitted to the hospital, where the urine amylase was found to be increased, and treatment for suspected acute pancreatitis was initiated. Following early improvement, the pain grew worse. On 2 April 1974, he was admitted to our hospital looking haggard and ill. The abdominal wall was taut and hard, and a tender resistance was felt in the right upper abdomen. Intestinal sounds were reduced. The hemoglobin was 11 g and the hematocrit was 32%; amylase activity in the serum and urine was normal. The serum amylase later rose to 900 U/1. ERP was performed on 22 April 1974. After filling the pancreatic duct with contrast, a stenosis of the pancreatic duct at the point of j unction of the head and body was evidenced by narrowing in the column and an extraductal collection (Figure 1). The findings were interpreted as a rupture of the pancreatic duct with traumatic pseudocyst. Subsequent laparotomy revealed a pseudocyst at the junction of the head and body of the pancreas. The radiographically demonstrated point of rupture and cyst formation were found. The cyst was opened and drained by means of a Roux-en-y anastomosis, and the patient's postoperative course was without complication. Case 2. During a soccer game on 13 March 1977, an 18-year-old lad suffered a blow from an opponent's knee to the middle of the abdomen somewhat to the left of the
255
Figure 1. ERP showing stenosis and rupture of the proximal pancreatic duct with extravasation of contrast medium into a traumatic pseudocyst. Note the filling of the duct beyond the point of rupture.
Figure 2. ERP showing extravasation from the distal pancreatic duct with contrast medium trickling down to the left of the lumbar vertebrae.
umbilicus. Vomiting occurred repeatedly. On admission the same day to an out-of-town hospital, he was noted to have severe pains in the left upper abdomen, slight muscular tautness, and normal intestinal peristalsis. His hemoglobin was 16.9 g, hematocrit 49%, WBC 19,000, serum amylase 8,200 U/I, urine amylase 24,000 U/I, calcium 2.4 mEq/1. On 16 March 1977 he was transferred to our hospital. Examination showed localized abdominal tenderness and muscular wall resistance to the left of the umbilicus. Intestinal peristalsis was active. On 17 March 1977 ERP was carried out. Following opacification of the pancreatic duct, the contrast medium flowed from the pancreatic duct close to the left edge of the spinal column. This was interpreted as extravasation due to rupture of the duct (Figure 2). Laparotomy was carried out on the same day. At operation, focal areas of calcified fat necrosis in the upper abdomen gave evidence of pancreatitis. After opening the lesser sac, the pancreas was seen to be jelly-like and covered with calcium flecks. Rupture was not grossly identifiable. The distal portion of the pancreas was resected without complication. The operative specimen showed subcapsular pancreatic duct rupture.
also, orientation with regard to the anatomical situation was not easy, even though before operation the conditions were made clear by ERP. In cases of acute injury to the upper abdomen, when the nature of the injury and the clinical and laboratory findings suggest pancreatic involvement, ERP should be carried out to obtain evidence of a break in continuity ofthe pancreatic duct. If one can anticipate the need for operation whi Ie the examination is being carried out, severe complications can be largely avoided by prompt surgical intervention. Our success in the identification of rupture of the pancreas, immediately after injury or several weeks later, strengthens our conviction that there should be a greater readiness to use the so-called emergency ERP.9 Identification of rupture of the duct by ERP simplifies the decision as to the necessity of surgical intervention, avoids superfluous exploratory laparotomies, and helps to prevent severe complications such as fistulas, cysts, hematomas, and abscesses.
DISCUSSION A consequence of acute injury to the pancreas can be rupture of the pancreatic duct with destruction of periductal tissue. When there is loss of continuity of the pancreatic duct, contrast ~edium instilled enters the periductal tissue,providing retrograde evidence ofthe existence of an injury to the pancreatic duct. In both of our cases, we were able to trace the duct as far as the periphery in spite of the injury. The risk of provoking acute pancreatitis, which has an occurrence rate of approximately 1 % with ERps,w can generally,be reduced by careful instillation of the contrast medium. Apart from this, the risk of pancreatitis is largely removed if an operation is immediately carried out. The surgical procedure is simplified by exact localization of apancreatic duct rupture. Bach 4 reports that of 6 patients with complete severance of the organ, the rupture was overlooked in 2 as a result of a pronounced chronic inflammation in the pancreas and in the surround ing tissue. Anderson 2 also reports cases where pancreatic injuries with rupture of the duct were overlooked during initial exploration because evaluation was hampered by extensive hematoma formation. In our cases
256
REFERENCES 1. ANANE-SEFAH ), NORTON LW, EISEMAN B: Operative choice and techni-
que following pancreatic injury. Arch Surg 110:161, 1975 2. ANDERSON CB, CONNORS JP, MEJIA DC, WISE L: Drainage methods in the
treatment of pancreatic injuries. Surg Gynecol Obstet 138:587. 1974 3. ANDERSON CB, WEISZ D, RODGER MR, TUCKER GL: Combined pan-
creaticoduodenaltrauma. Am J Surg 125:530, 1973 4. BACH RD, FREY CF: diagnosis and treatment of pancreatic trauma. Am
J
Surg 121:20, 1971 5. BELOHLAVEK D, KOCH H, ROSCH W, SCHAFFNER 0, MAEDER HU, FLORY L CLASSEN M, DEMLING L: Five years experience in endoscopic retrograde
cholangiopancreaticography (ERCP). Endoscopy 8: 115, 1976 FEUSEL H: Chirurgie der traumatischen Pankreaslasion. Notfallmedizin 3: 150, 1977 7. JONES RC, SHIRES GT: Pancreatic trauma. Arch Surg 102:424, 1971 8. LETTON AH, WILSON JP: Traumatic severance of pancreas treated by Roux-y-anastomosis. Surg Gynecol Obstet 109:473, 1959
6. FILLER D, SCHWEMMLE K, MUHRER KH,
9. MIEDERER WE, STADELMANN
10.
11.
12. 13. 14.
0,
LOFFLERA, WOBSTER E, KOITSCHWITZ K:
Die endoskopische retrograde Cholangio-Pankreatikographie (ERCP): Indikation, Methode, Wertigkeit und Risiko. Leber Magen Darm 4: 187, 1974 NEBEL OT, SILVIS SE, ROGERS G, SUGAWA C, MANDELSTAM P: Complications associated with endoscopic retrograde cholangiopancreaticography. Gastrointestinal Endoscopy 22:34, 1975 SAFRANY L, SCHON LEBEN K, WITTRIN G, RODIGER E: Die Hamobilie.Leber Magen Darm 5:229,1975 SCHWEMMLE K, GRABNER W, PHILLIP), BOTTICHER R: Die operative Therapie der Pankreasverletzungen. Bruns' Beitr klin Chir 220:675,1973 SCHWEMMLE K, SELBACH KD: Perforierende Bauchverletzungen SofortmaBnahmen. Notfallmedizin 2:732, 1976 WERSCHKY LR, JORDAN GL: Surgical management of traumatic injuries to the pancreas. Am Surg 116:768, 1968 GASTROINTESTINAL ENDOSCOPY