F. Lai*, A. Baldini*, C. Pagnini**, L. Pelagatti**, M. Rugna*** S. Magazzini****
*M.D. Emergency Department, Ospedale “Santo Stefano”, Prato, Italy
**School of Medicine, University of Florence, Italy
*********M.D. Director SOSD for Territorial Emergency System 118, USL Toscana Centro, Florence, Italy
****M.D. Chief Emergency Department, Ospedale “Santo Stefano”, Prato, Italy
ABSTRACT: The Authors present a rare case of blunt abdominal injury with pancreatic involvement. We discuss about a 19 years old man who injured his abdomen with bicycle handle-bar.
The Authors report a review of litterature in case of pancreatic fracture according to American Association for the Surgery of Trauma Classification (AAST) and Wong et al. as well.
Keywords: “Pancreas” or “Pancreatic”, “Traumatic”, “Transection” or “Fracture” or “Injury*” or “Disruption” or “Grade III Injury”, “Complete”
CASE: J.X. , a 19 year old male, accessed in Emergency Department (ED) for a blunt abdominal trauma due to a bicycle handle-bar injury occurred the day before the clinical evaluation. He presented stable vital parameters (Blood pressure: 119/86 mmHg; Heart rate: 97 bpm; Peripheric saturation: 99% room air), and presented for localized abdominal pain in epigastrium, exacerbated by palpation. The primary and secondary survey were quite normal. Arterial blood gas analysis showed a normal methabolical and respiratory pattern excepted for lactate who pointed in 2.2 mMol/L (normal values 0.5 – 1.5 mMol/L). Serum Amylase: 63.242 UI/L. Glasgow Coma Scale (GCS) showed 15.
The AMPLE valutation according to Adult Trauma Life Support (ATLS) pointed out any medical or surgical illness.
After clincal examination according to primary and secondary survey we performed an abdominal CT scan which showed an isolated post-traumatic complete transection of the pancreas between the body and the tail associated with retroperitoneal hemorragic collection; in addition there was a plentiful hemoperitoneum localized in splenic and pelvic seat as well. (See pictures n. 1-2)
The patient was initially treated with intravenous peripherical large bore Normal Saline 500 ml (14 Gauge), and supplementary Oxigen. We treated pain with intravenous Tramadol.
Two Red Packed Cells and plasma bag were requested. The patient was admitted in operatory room and treated with a distal pancretectomy and anastomosis with an intestinal loop.
Successively the Patient was admitted in Intensive Care Unit.
EPIDEMIOLOGY: The pancreas is a relatively uncommon organ to be injured in trauma, occurring in less than 2% of blunt trauma cases, and this injury is associated with considerably high morbidity and mortality. In the pediatric age, Pancreatic injury is rare as it has been reported to occur as low as 0.2% to 1.1% of all trauma. According to other studies, pancreatic injuries has an incidence of 0.4% of trauma presenting in both adult and pediatric populations.[2-4] Mortality from pancreatic injury has ranged from 9% to 34%. The isolated pancreatic injury is seen in only 30% of cases traumatic pancreatic injury, and only 5% of cases are related to fatal outcomes. Blunt pancreatic trauma is more common in the pediatric population as there is less fat for insulation. 
DISCUSSION: We have analized only the cases with a Grade of III and a complete transection at the neck of the Pancreas, between the body and tail. We haven’t fixed time limits to our research, and the oldest case we have found is of the year 1972
Two patients had a similar presentation to our case (i.e. bicycle handle-bar injury) . Frequent trauma related sports: A patient reported trauma during a rugby game , another during a football match for a trauma with a knee , an accidental fall from the horse in jumping an obstacle during a horse event , one during a ski session , A patient reported a safety belt trauma  and onother one patient reported a fracture of the pancreas following an aggression .
- Laboratory findings: serum amylase or amylase in diagnostic peritoneal lavage (DPL) fluid could be raised and can be useful in diagnosis, but there is poor correlation between amylase and pancreatic trauma because are non-specific. Amylase in DPL fluid is more sensitive and specific than blood or serum amylase in Pancreatic Trauma.
- RADIOLOGIC STUDIES: Diagnostic imaging are fundamental in the recognition, evaluation, grading and follow-up of pancreatic trauma:
- Conventional radiography: A plain X-ray of the abdomen in patients with pancreatic trauma is nonspecific
- Ultra Sounds (US) is easy, portable and economic but pancreatic injuries are difficult to diagnose with these techniques . Rather it is effective in the follow-up of complications such as pseudocysts, frequent after this kind of trauma. Real-time contrast-enhanced US is an useful technique in ED imaging, but its role is not a replacement for CT that remain the first option
- CT (Computed Tomography) is the gold standard: the fastest, simplest and least invasive (except US) diagnostic technique to show pancreatic trauma and its complications. The instrumental survey of choice for hemodynamically stable patients is the CT because it provides the safest and most comprehensive means of diagnosis of this kind of trauma . CT scans in the pancreatic trauma will point out:
- Frequently (20-40%), when CT is performed within 12 h after trauma, the organ may appear normal because pancreatic trauma may produce only little changes in the structure which may not be detectable.
- Lacerations are frequent at the junction between the body and tail due to compression against the spine
- Signs of pancreatic injury are: pancreatic volume focal enlargement, transection, laceration and altered enhancement.
- at the site of laceration or transection we can find hematoma and pseudocysts.
- Other techniques: In the past, ERCP was the only method available for evaluating pancreatic duct integrity even if recently has emerged MRCP
GRADING: Pancreatic trauma includes a wide range of injuries, from simple contusion injuries (grade I-II) to complete rupture of the pancreatic duct and loss of parenchyma (grade III-V).  The most used classification is the one proposed by American Association for the Surgery of Trauma (AAST) that includes five different Grade of seriousness.  (Picture n. 3)
Another classification is the one proposed by Wong et al. : a more simple method for grading severity on CT in pancreatic injury:
- grade A: pancreatitis or superficial laceration only
- grade B
- BI: deep laceration involving pancreatic tail
- BII: complete transection of pancreatic tail
- grade C
- CI: deep laceration involving pancreatic head
- CII: complete transection of pancreatic head
MEDICAL TREATMENT: The medical treatment of pancreatic trauma has as purpose the containment of the parenchymal damage and to the prevention of septic complications. It constitutes the only treatment practised in case of low-grade injury and in cases under observation. The Basic Treatment of Pancreatic trauma consists of:
- ABCDE valutation and treatment
- Cristalloid infusion
- Bowel rest
- Nasogastric suction
- Nutritional support and Fluid
- Bladder catheter
Usefully administration drugs are: antienzymes, octreoide, anti H2 drugs, antibiotic, analgesics and parenteral nutrition.
SURGICAL TREATMENT: Grades I and II treatment consists in non-operative management techniques or simple drainage, whereas grade III or higher injuries often require resection with possible reconstruction and/or drainage procedures.
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