Clinical History
9-year-old boy who fell off his kickbike and was hit by the handlebar. He presented with abdominal pain. CT shows a 6 cm mass in the head of the pancreas that does not enhance after intravenous contrast medium injection.
Imaging Findings
9-year-old boy who 6 hours prior to admission had fallen on his kickbike with a direct blow from the handlebar into his epigastrium. Slight but progressive abdominal pain. On admission he had tenderness in the epigastrium and in his left upper quadrant. He also vomits several times. Plain CT of the abdomen shows an enlargement of the pancreas partly with attenuation values like blood. The normal low attenuating retroperitoneal fat is replaced by high attenuating blood or oedema surrounding vessels indicating involvement of the retroperitoneal space. The stomach is dislocated anteriorly. After intravenous injection there is normal enhancement of the tail of the pancreas and part of the head of the pancreas. There is an unenhancing cleft between the body and head of the pancreas. The pancreatic duct is not dilated. The stomach again could be seen dislocated anteriorly. The descending portion of the duodenum is somewhat dislocated laterally. There is no fluid or blood in the upper abdomen. In the lower abdomen (pouch of Douglas), there is s moderate amount of fluid. The patient was hospitalised and put on parenteral nutrition. His amylase was 27 µkat/litre. Other biochemical tests were normal.
Discussion
The pancreas is located retroperitoneally and seldom suffers from abdominal trauma. Its fixed position anteriorly to the vertebral column however also makes it vulnerable to compression injuries. Symptoms of pancreatic trauma are non-specific and the diagnosis is often made late. Due to its retroperitoneal location pancreatic injuries are difficult to diagnose with peritoneal lavage. Pancreatic injuries are found in 0.5% of patients with abdominal trauma. The classic blunt trauma is caused by a direct blow from a fall, especially in a child falling from a bicycle where the steering wheel or handlebar is the cause of injury. Such a blow may disrupt the neck or body of the pancreas as it passes the spine resulting in a laceration of the pancreas.
Pancreatic injuries have a high mortality rate (about 20%, depending on the grade of injury). Most patients with pancreatic injuries have other intraabdominal concomitant injuries which contribute to the mortality rate. The injury to the pancreas causes leakage of pancreatic juice into the pancreatic tissue and surrounding retroperitoneum. This may cause severe pancreatitis and peripancreatitis. The CT examination cannot with any degree of certainty visualise the integrity of the pancreatic duct. An initial CT or MR examination may be relatively normal while a later examination after leakage of pancreatic juice may show extensive injuries. Repeat examination must therefore be used often. Major complications include pancreatic fistula, pseudocysts, pancreatic abscesses, and necrosis of parenchyma. It is therefore important to establish drainage of leaking pancreatic juice which can be done as a subtotal pancreatectomy with an anastomosis between the jejunum and the pancreatic duct. However, if no complication occurs, the pancreas tends to heal without any sequelae. Pseudocysts may however be present for a long time.
Our case demonstrates a relatively unusual finding with high attenuation in a blood clot in the transsected pancreas.
Differential Diagnosis List
Pancreatic trauma with pancreatic laceration.
Final Diagnosis
Pancreatic trauma with pancreatic laceration.
