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Pancreatic transection after hand injury in a child: a case report

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https://www.eduzhai.net Clinical Medicine and Diagnostics 2015, 5(3): 50-51 DOI: 10.5923/j.cmd.20150503.04 Pancreatic Transection in a Child Following Handlebar Injuries: A Case Report Azhar Amir Hamzah1,*, Azreen Syazril Adnan2, Abdul Kareem3, Amer Hayat Khan4, Kashi Ullah Khan4 1Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia 2Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia 3Department of Radiology, School of Medical Sciences, Universiti Sains Malaysia 4Department of Clinical Pharmacy, School of Pharmaceutical Sciences, USM, Penang, Malaysia Abstract Background: Blunt abdominal trauma can cause multiple internal injuries. Computed tomography (CT) imaging is currently used to assess clinically stable patients with blunt abdominal trauma. Case study: A 9 year old boy, presented with epigastric pain for 3 week duration after a fall on a bicycle handlebar. Patient was treated conservatively and later presented with infected pseudo cyst. Contrast-enhanced Computed Tomography (CECT) was done to reveal a transacted pancreas with pseudo cyst and gross ascites. A distal pancreatectomy was then done and post operatively uneventful. Conclusions: Non-operative management of blunt abdominal trauma is the treatment of choice in children to preserve total function of organ, the most important problem is the identification of ductal injuries. Keywords Handlebar injury, Blunt abdominal trauma, Paediatric, Ascites, Pseudo 1. Introduction Pancreatic injury is the fourth common abdominal injury which constitutes less than 10% of all abdominal injuries. Bicycle accidents are by far the most common cause of pancreatic injuries in the children, accounting for 42-75% of cases. Appropriate management of the injured pancreas has been controversial. With the advent of the computerized tomography scan, surgeons have tended to manage pancreatic injuries non-operatively. Isolated pancreatic injuries are extremely rare. We describe a case of pancreatic transaction in a 9 year old boy who was failed to treat conservatively. 2. Case Report A 9 year old boy, presented with epigastric pain for 3 week duration after a fall on a bicycle handlebar. On admission patient was comfortable but mildly dehydrated. The vital signs were stable and was afebrile. The abdomen was not distended, but tender and guarding over the epigastric region. Serum amylase on admission was 1864 U/L (Reference Normal Range 40-140 U/L). Serum amylase test measures the amount of amylase in a sample of blood taken from a * Corresponding author: drazhar786@hotmail.com (Azhar Amir Hamzah) Published online at https://www.eduzhai.net Copyright © 2015 Scientific & Academic Publishing. All Rights Reserved vein to find pancreatitis and other pancreatic disease. It can also be found by taking urine sample where it is called diastase. Patient was later diagnosed with pancreatitis secondary to trauma. Urgent ultra-sonogram (USG) abdomen showed resolving contusion on the body of pancreas measuring 1.1 x 1.0cm. Patient was treated conservatively. Two week later the child complains of epigastric pain and low grade fever. The vital signs were stable with low grade temperature. The abdomen mildly distended and tender at epigastric region. An urgent ultra-sonogram (USG) abdomen was done revealed pancreatic contusion complicated with ascites and pseudo cyst. Contrast-enhanced Computed Tomography (CECT) abdomen was done which revealed features suggestive of infected pancreatic pseudo cysts. The serum Amylase remained high (2822 U/L) with urine Diastase of 1259 U/L (Reference Normal Range 25-415 U/L). However the patient was afebrile and the vital signs were all the while stable. Despite the conservative treatment, the symptoms progress with increasing abdominal distension and associated abdominal pain. A repeat Contrast-enhanced Computed Tomography (CECT) abdomen was done 2 weeks later which reported as transacted pancreas with pseudo cyst and gross ascites. The patient was subsequently referred to tertiary Paediatric Surgical Centre for distal pancreatectomy. Post operative recovery was uneventful and was discharged well 12 days after the operation. On regular follow up, three month after the surgery, the child was well, active with satisfactory weight gain. Clinical Medicine and Diagnostics 2015, 5(3): 50-51 51 Figure 1. Axial CECT shows gross ascites discontinuity between the head and body with small cystic lesion in between C.A. Graham et al. mentioned that about 67% of patient developed pancreatic pseudo cyst which are common after paediatric pancreatic injury [3]. Most children settle with conservative management, with a minority requiring pseudo cyst drainage. Serial serum amylase estimation can be used usefully to monitor the development and resolution of pseudo cysts. Surgical management is undertaken for control of haemorrhage, renal injury, suspicion of pancreatic-duct rupture, or failure of conservative management. For a simple contusion or laceration without ductal injury, drainage alone is sufficient. Injuries of the body and tail of the organ with complete ductal disruption are best treated by distal pancreatic resection without splenectomy if possible [6, 7]. Current patient underwent distal pancreatectomy (with preservation of the spleen) for transaction between the neck and body of the pancreas associated with a pseudo cyst after a 6-week trial of conservative management. The overall mortality of pancreatic injury has remained near 20%, reflecting the severity of injuries, diagnostic delays, and associated injuries [6]. 4. Conclusions Figure 2. CT of abdomen showing gross ascites with pseudocyst 3. Discussion Blunt traumatic injuries of pancreas are relatively rare and non-operative management is the treatment of choice in children to preserve total function of the organ, the most important problem is the identification of ductal injuries. Computed tomography has an essential part of the management of the children with pancreatic trauma. Blunt abdominal trauma is the most common cause of pancreatic injury in children; over 50% of cases of pancreatitis in children are caused by blunt trauma [1, 2]. The typical causes are the bicycle handlebar injury which was the commonest cause comprises about 62% of the cases [3]. Diagnosis requires high degree of suspicion. Usually the initial complaint is vague and non specific. Physical signs include epigastric tenderness in the early and frank peritonitis in late presentation. Serum hyperamylasemia is neither sensitive nor specific. Radiographic examinations are less efficient in the diagnosis of blunt pancreatic injury. Direct imaging of the pancreas by ultrasound (US) and computed tomography (CT) has contributed considerably to accurate assessment of pancreatic morphology by non-invasive means [4, 5]. US has numerous advantages in children: it is non-invasive, non-irradiating, repeatable, fast, and easy to perform. Endoscopic retrograde cholangiopancreatography (ERCP) has been used to delineate the main pancreatic ductal anatomy after pancreatic trauma as a prelude to potential surgery [4]. It has been advocated that endoscopic retrograde cholangiopancreatography (ERCP) is an essential part of the management of children with pancreatic trauma [4]. REFERENCES [1] Akhrass R, Yaffe MB, Brandt CP, Pancreatic trauma: A ten year multi institutional experience. Am Surg 1997; 63: 598-604. [2] Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children. Journal of Trauma 1997; 42: 1097-1100. [3] C.A. Graham et. al. Pancreatic trauma in Scottish children; J.R CoU. Surg. Edinh., 45. Aug 2000, 223-226. [4] Hall RI, Lavelle MI, Venebles CW. Use of ERCP to identify the site of traumatic pancreatitis duct in children. British Jour of Surgery 1986; 73: 411-2. [5] Ivancev K, Kullendor. CM (1983) Value of computed tomography in traumatic pancreatitis in children; Acta Radiol Diag 24:441-444. [6] M.C. Plancq á J. Villamizar á J. Ricard J.P. Canarelli; Management of pancreatic and duodenal injuries in pediatric patients; Pediatr Surg Int (2000) 16: 35-39. [7] McGahren ED, Magnuson D, Scha.er RT, Tapper D (1995) Management of transacted pancreas in children. Aust N Z JSurg 65: 242-246.

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