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Traumatic Pancreatic Transection with Abdomino-Pelvic Pseudocyst Formation
Traumatic Pancreatic Transection with Abdomino-Pelvic Pseudocyst Formation
A
10-year-old boy was admitted with complaints of an abdominal injury during a fall followed by mild epigastric pain. Seven days later, he developed progressive abdominal distension requiring repeated paracentesis. Referred as a case of refractory cryptogenic ascites, he was admitted and evaluated. Abdominal fluid analysis showed neutrophilic leucocytosis, fluid amylase, and lipase levels of 21 512 and 1852 IU/L, respectively, and serum-ascites albumin gradient of 1.0 (non-portal hypertension ascites), while serum amylase levels were 419 IU/L. Computerized tomography scan of abdomen revealed near-complete transection of pancreas at the neck-body junction and a large abdominopelvic pseudocyst (Figure, A). The child was managed conservatively, in view of poor general condition and sepsis, with antibiotics, octreotide use, percutaneous external drainage, and nutritional rehabilitation. Repeat computerized tomography scan of the abdomen (after 1 month) showed pancreas with normal bulk outline and enhancement, resolution of both pancreatic disruption and abdomino-pelvic pseudocyst (Figure, B). Pancreatic traumatic injuries are a rare entity in the pediatric population but carry high morbidity and mortality if diagnosis in delayed. As in adults, they are graded as per standard Organ Injury Scaling Committee of the American
Association for the Surgery of Trauma classification.1 Though definite pediatric guidelines are lacking, as in adults, milder grades are managed conservatively.2,3 Ideal management of advanced grades (as in our case) still remains controversial, with literature, although still scarce, favoring surgical intervention.2,3 In contrast, our patient showed excellent results with medical management only, as described above.4,5 Diligent and meticulous nutritional rehabilitation and multimodality approach hold the key to success.4 n Vikrant Sood, MD Bikrant Bihari Lal, MD Seema Alam, MD Dinesh Rawat, MD Rajeev Khanna, MD Department of Pediatric Hepatology
S. Rajesh, MD Department of Radiology Institute of Liver and Biliary Sciences New Delhi, India
References available at www.jpeds.com
Figure. A, Axial image of abdomen from the contrast-enhanced computed tomography scan of the child demonstrating nearcomplete transection of pancreatic parenchyma at the neck-body junction (black arrow) with a large abdomino-pelvic pseudocyst (white arrow). B, Image from the repeat contrast-enhanced computed tomography showing normal pancreatic outline (black arrow) and resolution of the pseudocyst.
J Pediatr 2015;166:1094. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.12.060
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Vol. 166, No. 4 April 2015
References 1. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA. Organ injury scaling II. Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990;30:1427-9. 2. Ruszink o V, Willner P, Olah A. Pancreatic injury from blunt abdominal trauma in childhood. Acta Chir Belg 2005;105:283-6.
3. Stringer MD. Pancreatic trauma in children. Br J Surg 2005;92:467-70. 4. Abdo A, Jani N, Cunningham SC. Pancreatic duct disruption and nonoperative management: the SEALANTS approach. Hepatobiliary Pancreat Dis Int 2013;12:239-43. 5. Bosman-Vermeeren JM, Veereman-Wauters G, Broos P, Eggermont E. Somatostatin in the treatment of a pancreatic pseudocyst in a child. J Pediatr Gastroenterol Nutr 1996;23:422-5.
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A
10-year-old boy was admitted with complaints of an abdominal injury during a fall followed by mild epigastric pain. Seven days later, he developed progressive abdominal distension requiring repeated paracentesis. Referred as a case of refractory cryptogenic ascites, he was admitted and evaluated. Abdominal fluid analysis showed neutrophilic leucocytosis, fluid amylase, and lipase levels of 21 512 and 1852 IU/L, respectively, and serum-ascites albumin gradient of 1.0 (non-portal hypertension ascites), while serum amylase levels were 419 IU/L. Computerized tomography scan of abdomen revealed near-complete transection of pancreas at the neck-body junction and a large abdominopelvic pseudocyst (Figure, A). The child was managed conservatively, in view of poor general condition and sepsis, with antibiotics, octreotide use, percutaneous external drainage, and nutritional rehabilitation. Repeat computerized tomography scan of the abdomen (after 1 month) showed pancreas with normal bulk outline and enhancement, resolution of both pancreatic disruption and abdomino-pelvic pseudocyst (Figure, B). Pancreatic traumatic injuries are a rare entity in the pediatric population but carry high morbidity and mortality if diagnosis in delayed. As in adults, they are graded as per standard Organ Injury Scaling Committee of the American
Association for the Surgery of Trauma classification.1 Though definite pediatric guidelines are lacking, as in adults, milder grades are managed conservatively.2,3 Ideal management of advanced grades (as in our case) still remains controversial, with literature, although still scarce, favoring surgical intervention.2,3 In contrast, our patient showed excellent results with medical management only, as described above.4,5 Diligent and meticulous nutritional rehabilitation and multimodality approach hold the key to success.4 n Vikrant Sood, MD Bikrant Bihari Lal, MD Seema Alam, MD Dinesh Rawat, MD Rajeev Khanna, MD Department of Pediatric Hepatology
S. Rajesh, MD Department of Radiology Institute of Liver and Biliary Sciences New Delhi, India
References available at www.jpeds.com
Figure. A, Axial image of abdomen from the contrast-enhanced computed tomography scan of the child demonstrating nearcomplete transection of pancreatic parenchyma at the neck-body junction (black arrow) with a large abdomino-pelvic pseudocyst (white arrow). B, Image from the repeat contrast-enhanced computed tomography showing normal pancreatic outline (black arrow) and resolution of the pseudocyst.
J Pediatr 2015;166:1094. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.12.060
1094
Vol. 166, No. 4 April 2015
References 1. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA. Organ injury scaling II. Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990;30:1427-9. 2. Ruszink o V, Willner P, Olah A. Pancreatic injury from blunt abdominal trauma in childhood. Acta Chir Belg 2005;105:283-6.
3. Stringer MD. Pancreatic trauma in children. Br J Surg 2005;92:467-70. 4. Abdo A, Jani N, Cunningham SC. Pancreatic duct disruption and nonoperative management: the SEALANTS approach. Hepatobiliary Pancreat Dis Int 2013;12:239-43. 5. Bosman-Vermeeren JM, Veereman-Wauters G, Broos P, Eggermont E. Somatostatin in the treatment of a pancreatic pseudocyst in a child. J Pediatr Gastroenterol Nutr 1996;23:422-5.
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