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Case of the Month

February 2011

Patient Data: 12 year old boy

Clinical Info: The boy had fallen of his bike and had sustained a blunt abdominal trauma by the handle bar of his bike 10 hours prior to the ultrasound examination. He was hemodynamically stable, but had pain in his left upper abdomen.

Transverse image of the pancreas. There is a minimal contour irregularity of the anterior aspect of the pancreas

Transverse image through the lower abdomen with some fluid / blood anterior of the bladder

Longtudinal image of the lower abdomen showing some fluid / blood cranial to the bladder

No fluid around the liver (Morrisons pouch)

No fluid around the normal looking spleen

No fluid around the spleen and left kidney transverse

Transverse image of the pancreas with some fluid around the tail

Transverse image of the pancreas. No flow in the fluid around the tail. Normal splenic vein. A partial splenic rupture was considered the most likely diagnosis. Because the patient was stable with minor symptoms, we advised a control examination the following day.

The patient was examined two days later because the surgeon had found him hemodynamically stable and had still minor symptoms. The pancreas is now surrounded by fluid and at the site of the irregularity in the contour, there is now a defect filled with fluid indicating a complete rupture

Transverse image of the pancreatic rupture

36833-5114837_20101208_ABDOMEN-__0006.AVI.SWF videoclip shows the rupture of the pancreas

36832-5114837_20101208_ABDOMEN-__0004.AVI.SWF videoclip of the fluid collection around the pncreas tail

There is now a larger fluid collection around the pancreatic tail. Transverse view

There is now a larger fluid collection around the pancreatic tail. Longitudinal view

36831-5114837_20101208_ABDOMEN-__0002.AVI.SWF videoclip shows the fluid collection

36836-Mijn_Film.wmv.SWF A CT scan showed the same findings. An ultrasound guided percutaneous drainage procedure of the fluid collections was performed

Pancreas after percutaneous drainage with the drain next to the pancreas tail

Pancreas after percutaneous drainage with a small effusion and the drain next to the pancreas tail

Pancreas some time later after percutaneous drainage of the fluid collections and conservative treatment. The effusions are gone

The site of the rupture is still visible as an irregularity of the contour

The pancreatic duct in the distal part of the pancreas can be followed to the site of the rupture

The fluid collection between the pancreatic tail and the spleen is gone

Detail of the pancreatic tail without effusion

Acute pancreatic ruptures are difficult to diagnose with ultrasound. When there is no blood in the defect, they can easily be overlooked. Ultrasound is very sensitive in detecting fluid, but parenchymal lesions can sometimes be missed. CT is more sensitive than ultrasound in detecting parenchymal lesions. The patient was discussed with a larger pediatric trauma centre, but because he remained hemodynamically stable the treatment of choice remained conservative treatment. The fluid collections that developed were percutaneously drained under ultrasound guidance.

For more examples of pancreatic ruptures see

Isolated traumatic pancreatic rupture.Tsai MT, Sun JT, Tsai KC, Lien WC.
Am J Emerg Med. 2010 Jul;28(6):745.e3-4

Percutaneous drainage treatment of traumatic pancreatic rupture with pancreatic transection.Martinez-Ramos D, Cifrián-Pérez M, García-Vila JH, Salvador-Sanchís JL, Hoashi JS.
Gastroenterol Hepatol. 2010 Feb;33(2):102-5.

Copyright © Dr. T.S.A. Geertsma, Ziekenhuis Gelderse Vallei, Ede, The Netherlands. All rights reserved.

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