ECG Case n° 2

A 57 year-old-patient is brought in Emergency Department by ambulance complaining of fever, swelling and erythema of the left leg .

Medical History: not relevant.

Vital Signs: BP 130/80 mmHg, HR 90 bpm, SpO2 96% room air, RR 22/min, GCS 15, T 38°C.

Arterial Blood Gas analysis:

ECG. 1

ECG ANSWER and INTERPRETATION

Rate:

  • 85 min

Rhythm:

  • Regular P waves

Axis:

  • -75°

Intervals:

  • PR – normal (<200ms) and regular
  • QRS – Wide (>120ms); rSR’ morphology V1-V3: RBBB.
  • QT – 360ms (QTc Bazett 430ms)

Waves and Segments:

  • P waves: left atrial abnormality (negative component>positive component)
  • Q waves DII-DIII-aVF: >0.04ms and Q>R
  • S wave in DI
  • ST depression V1-3 and DI-aVL
  • T waves: negative V1-V3, DIII, aVR
  • SIQIIITIII (McGinn-White): S wave in DI, Q waves DIII, negative T waves in DIII

DIFFERENTIAL DIAGNOSIS

The ECG changes described may be seen with any cause of acute or chronic disease that causes right ventricular strain:

AcuteChronic
Severe pneumonia
Exacerbation of COPD /asthma
Pneumothorax
Recent pneumonectomy
Upper airway obstruction
Pulmonary Embolism  
Chronic obstructive pulmonary disease
Recurrent small PEs
Cystic fibrosis
Interstitial lung disease
Severe kyphoscoliosis
Obstructive sleep apnoea
Pulmonary Ipertension

OUTCOME

There were no focal changes in lung parenchyma on chest radiographs.

The patient was allergic to iodinated contrast media (anaphylactic shock): A pulmonary scintigraphy was then performed in the suspicion of pulmonary embolism.

IMG. 1-4: Pulmonary scintigraphy

Ventilation images document areas of impaired ventilation in the posterior basal area of the left lung; Perfusion images document perfusion deficit in the posterior basal segment.

Conclusion: compatible with pulmonary embolism.

The patient was treated with Apixaban and discharged after a few days.

TRICKS

ECG changes associated with acute pulmonary embolism are nonspecific and may be seen in other condition [1-5]. The ECG in Pulmonary Embolism (PE) lacks sensitivity and specificity: it is neither sensitive nor specific enough to diagnose or exclude PE.

ECG changes in PE are related to dilation of the right atrium and right ventricle, right ventricular ischaemia, heart rotation and position shift, increased sympathetic tone due to pain, anxiety and hypoxia.

The most common findings are sinus tachycardia (44%) and nonspecific ST-segment and T-wave changes (50 %). The most specific finding is simultaneous T wave inversions in the inferior (II, III, aVF) and right precordial leads (V1-4), representing high pulmonary artery pressures; T wave inversion in lead V1 plus lead III was only seen in 1% of ACS patients versus 88% of patients with PE. 

Other ECG changes in pulmonary embolism include:

  • Complete or incomplete RBBB (18%)
  • Right ventricular strain pattern –  T wave V1-4 ± II, III, aVF
  • Right axis deviation – (16%)
  • Dominant R wave in V1 representing acute right ventricular dilatation.
  • Right atrial enlargement  – P wave in lead II > 2.5 mm (9%)
  • SIQIIITIII –neither sensitive nor specific. Abnormalities historically considered to be suggestive of PE (S1Q3T3 pattern, right ventricular strain, new incomplete right bundle branch block) are uncommon (less than 10 percent) [6-7].
  • Clockwise rotation
  • Atrial tachyarrhythmias – AF, flutter, atrial tachycardia (8%)

Normal ECG is present in 9-26% of cases.

ECG abnormalities that are associated with a poor prognosis [1,2,4]:

●Atrial arrhythmias

● Right heart strain + RBBB

●Bradycardia (<50 beats per minute) or tachycardia (>100 beats per minute)

●Complete right bundle branch block

●Inferior Q-waves (leads II, III, and aVF)

●Anterior ST-segment changes and T-wave inversion (V1-V3)

●SIQIIITIII


AUTHORS

Dr. Lorenzo Pelagatti

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

High Dependency Unit – AOU Careggi – Florence, Tuscany, Italy


Dr. Franco Lai

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

REFERENCES

  1. Geibel A, Zehender M, Kasper W, Olschewski M, Klima C, Konstantinides SV. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. Eur Respir J. 2005 May;25(5):843-8. doi: 10.1183/09031936.05.00119704. PMID: 15863641.
  2. Ferrari E, Imbert A, Chevalier T, Mihoubi A, Morand P, Baudouy M. The ECG in pulmonary embolism. Predictive value of negative T waves in precordial leads–80 case reports. Chest. 1997 Mar;111(3):537-43. doi: 10.1378/chest.111.3.537. PMID: 9118684.
  3. Rodger M, Makropoulos D, Turek M, Quevillon J, Raymond F, Rasuli P, Wells PS. Diagnostic value of the electrocardiogram in suspected pulmonary embolism. Am J Cardiol. 2000 Oct 1;86(7):807-9, A10. doi: 10.1016/s0002-9149(00)01090-0. PMID: 11018210.
  4. Shopp JD, Stewart LK, Emmett TW, Kline JA. Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Acad Emerg Med. 2015 Oct;22(10):1127-37. doi: 10.1111/acem.12769. Epub 2015 Sep 22. PMID: 26394330; PMCID: PMC5306533.
  5. Co I, Eilbert W, Chiganos T. New Electrocardiographic Changes in Patients Diagnosed with Pulmonary Embolism. J Emerg Med. 2017 Mar;52(3):280-285. doi: 10.1016/j.jemermed.2016.09.009. Epub 2016 Oct 11. PMID: 27742402.
  6. Panos RJ, Barish RA, Whye DW Jr, Groleau G. The electrocardiographic manifestations of pulmonary embolism. J Emerg Med. 1988 Jul-Aug;6(4):301-7. doi: 10.1016/0736-4679(88)90367-8. PMID: 3225435.
  7. Thames MD, Alpert JS, Dalen JE. Syncope in patients with pulmonary embolism. JAMA. 1977 Dec 5;238(23):2509-11. PMID: 578884

SITOGRAPHY

  1. Dr Smith’s ECG Blog
  2. https://litfl.com 

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

ECG Case n°1

A 75-year-old man is brought in Emergency Department by ambulance complaining of breathlessness and dyspnoea.

Medical History: Former smoker, COPD.

BP 133/77 mmHg, SpO2 96% room air, RR 22/min, GCS 15.

HR is fixed at 215 bpm. Is this SVT? ANRT? AVNRT? Atrial flutter? 

ECG. 1A-B

ABG room air: pH 7.391, pO2 95.4, pCO2 41.3, Hb 15.8 g/dL, K+ 5.3, Na+ 135, Ca2+ 1.14, Lac 2.2, Glu 152, HCO3- 25.

ECG ANSWER and INTERPRETATION

Rate:

  • 215

Rhythm:

  • Regular without P waves

Axis:

  • +90°

Intervals:

  • PR – No visible P waves
  • QRS – Normal (<120ms)
  • QT – 280ms (QTc Bazett 440ms)

Segments:

  • ST depression V3-6 and DIII-aVF

DIFFERENTIAL DIAGNOSIS

AVNRT– Regular 
– Rate ~140-280 bpm
– QRS complexes have a morphology that is usual for the subject under examination
– Narrow QRS complexes (< 120 ms) unless there is co-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
– P waves if visible exhibit retrograde conduction with P-wave inversion.
– P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III, aVF. They may be buried within (more frequently), visible after, or very rarely visible before the QRS complex
– The atrial and ventricular rates are the same
– ST-segment depression may be observed
AVRT– Regular
– Rate 200-300 bpm
– QRS complexes have a morphology that is usual for the subject under examination
– Narrow QRS complexes (< 120 ms) unless there is co-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
– P waves if visible exhibit retrograde conduction with P-wave inversion.
– Retrograde P waves are usually visible, with a long RP interval (P-QRS > QRS-P)QRS < 120ms unless pre-existing bundle branch block, or rate-related aberrant conduction
– The atrial and ventricular rates are the same
– ST-segment depression may be observed
Atrial Flutter– Narrow complex tachycardia
– Regular atrial activity at ~250-300 bpm (more frequently ~300 bpm)
– “Saw-tooth” pattern of P waves (typically in II, III, aVF, V1)
– Upright flutter waves in V1 that may resemble P waves
– Ventricular rate depends on AV conduction ratio; QRS rate is a fraction of the atrial rate (1/2 = 150 bpm; 1/3 = 100 bpm: 1/4 = 75 bpm)

OUTCOME

Flutter waves are not clearly seen (flutter with a 1:1 block?); Alternatively, this may just be rapid SVT (AVNRT/AVRT).

Given doubt regarding the rhythm, and a fixed heart rate of 220 bpm that is often seen in atrial flutter, we chose to administer adenosine to assist in differentiating/ treating the cause.

6 mg of adenosine was administered without benefit.

Then 12 mg of adenosine was administered.

ECG 2.

Rhythm strip reveals flutter waves. The patient does not cardiovert to sinus rhythm following adenosine administration; instead, the degree of AV block is increased, revealing sawtooth flutter waves.

Verapamil 5 mg 1 fl + Normal Saline 250 ml was administered, with good rate control

ECG 3.

INTERPRETATION:

ECG 1 A-B: Atrial Flutter 1:1 Block

ECG 3: Atrial Flutter 2:1 Block

  • Narrow Complex Tachycardia
  • Ventricular rate 120 bpm
  • Sawtooth flutter waves are seen in the inferior leads II, III, aVF.
  • Upright flutter waves in V1 appear either as pseudo-P waves or as notches in the T wave.
  • There is a clear 2:1 relationship between the flutter waves (300 bpm) and QRS complexes (120 bpm).

TRICKS

IMG. 1: Mechanism and electrocardiographic pattern of typical atrial flutter (left) and reverse typical atrial flutter (right). (1) 
 
Anticlockwise Reentry (typical atrial flutter) (2): (90% of cases of atrial flutter). Retrograde atrial conduction produces:
Inverted flutter waves in leads II,III, aVF
Positive flutter waves in V1 — may resemble upright P waves
 
 Clockwise Reentry (reverse typical atrial flutter) (2): This variant produces the opposite pattern:
Positive flutter waves in leads II, III, aVF (ECG. 1A-B,2,3)

AUTHORS

Dr. Lorenzo Pelagatti

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

High Dependency Unit – AOU Careggi – Florence, Tuscany, Italy


Dr. Franco Lai

Emergency Department – Nuovo Ospedale di Prato S. Stefano – Prato, Tuscany, Italy

REFERENCES

  1. F. García Cosío, A. Pastor, A. Núñez et al. Atrial Flutter: an Update Rev Esp Cardiol. 2006;59(8):816-31. DOI: 10.1016/S1885-5857(07)60047-4.
  2. Marine et al. Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter. Circulation. 2001;104:1153–1157
  3. Jabbour F, Grossman SA. Atrioventricular Reciprocating Tachycardia. 2021 Aug 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30969587.

SITOGRAPHY

  1. Dr Smith’s ECG Blog – Atrial Flutter
  2. https://litfl.com – Atrial Flutter, SVT, AVRT

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

PHYTOBEZOAR SMALL BOWEL OBSTRUCTION ASSOCIATED WITH MECKEL’S DIVERTICULUM: A RARE CASE REPORT

Lai F.*, Baldini A.***, Balzarini B.*,  Franci A.**, Lamia D.**, M.Rugna**** Magazzini S.*****

* Emergency Department, Ospedale S.Stefano, Azienda USL Toscana Centro, Prato, Italy

** Nurse of Emergency Department, Ospedale S. Stefano, Azienda USL Toscana Centro, Prato, Italy

*** Director of Emergency Department, Ospedale S. Stefano, Azienda USL Toscana Centro, Prato, Italy

 ****M.D. Director SOSD for Territorial Emergency System 118, USL Toscana Centro, Florence, Italy

*****Chief of Emergency Department, Ospedale S. Stefano, Azienda USL Toscana Centro, Prato, Italy

Contacts: dott.francolai@gmail.com

ABSTRACT

Introduction: Phytobezoars are the most frequently observed type and account for approximately 40% of total number of reported bezoars.

Phytobezoar is a trapped mass in the gastrointestinal system, that consists of components of indigestible vegetable material, most commonly from  pulpy fruits, orange pits, seeds, roots or leeves.

Meckel’s diverticulum (MD) is a congenital anomaly due to the presence of a residue of the omphalo-mesenteric duct organized as a diverticulum, a completely blind sac at the ileal level.

The Authors report a rare case of small bowel obstruction due to phytobezoar associated to Meckel’s diverticulum.

 Discussion: Bowel obstruction due to a phytobezoar in a Meckel’s diverticulum is rare: only few cases have been reported in litterature. MD complications are rare and phytobezoar is one of them with only few cases described in litterature.

Keywords: bowel obstruction, phytobezoar, Meckel’s diverticulum, intussusception.


CASE REPORT

   The Authors describe a 67 years old male presented in Emergency Department (ED) with abdominal pain associated to vomiting, no fever and  no other symptoms were referred.

  The patient referred prior surgery for intussusception in pediatric age.

The  blood pressure was 154/81 mmHg, the heart rate of 70 beats for minute, SpO2 was 98% in room air.

The physical exam showed normal findings for thorax and heart sounds. Abdomen was painful and no peristaltic sounds were present and  was defended.

Blood samples were performed and showed: a normal renal and hepatic function, with normal coagulation pattern, hemochrome showed: WBC 11.9 10^3 µ/L; GR 5.59 10^6 µ/L, Hb 15.7 g/Dl, PLT: 215 10^ 3; PCR 0.62 mg/Dl. Sars-COV2 buffer sample was negative.

Blood gas analysis showed normal EAB with a modest ipochloremia.; no methabolic acidosis was present, and lactate showed a normal range as well.

Eco-fast showed normal patterns and no bladder globe.

The strong suspect was related to rule out appendicitis, diverticulitis, cholangitis or cholecystitis, bacterial peritonitis and intestinal perforation. For this reasons was perfomed an abdomen CT scan with intravenous contrast agent which pointed out  in the lumen of distal ileum in the median hypogatsric site the presence of a coarse roundish component with a fecaloid-like appearance (maximum longitudinal extension of 11 cm and maximum axial dimensions of 9 cm) in the first hypothesis bezoar, which determines distension and hydro-aereal levels in the tenual loops upstream to the distal jejunal tract. On the right lateral side of the ileum, at this level, there is a small parietal ejection extended by fluid (likely Meckel’s diverticulum).

CT Scan findings are showed in Figures 1, 2, 3 and 4.

After CT scans a more accurate patient interview reported that the previous day he had eaten two oranges and that he also ate the peel.

Finally a surgical consultation was performed and the patient was admitted in Surgery for small bowel obstruction due to phytobezoar.

DISCUSSION

A bezoar is a tightly packed collection of partially digested or undigested material that most commonly occurs in stomach. Gastric bezoars can occur in all age groups and often occur in patients with behaviour disorders, abnormal gastric emptying, or altered gastrointestinal anatomy. Many bezoars are asymptomatic, but some

cause symptoms. Some bezoars can be dissolved chemically, others require endoscopic removal, and some even require surgery [1].

Bezoars are classified according to their composition:

  • Phytobezoars (most common) are composed of indigestible fruit and vegetable matter such as fiber, peels, and seeds.
  • Trichobezoars are composed of hair.
  • Pharmacobezoars are concretions of ingested drugs (particularly common with sucralfate and aluminum hydroxide gel).
  • Diospyrobezoars, a subset of phytobezoars, result from excessive intake of persimmon and occur most often in regions where the fruit is grown.
  • Lactobezoars are composed of milk protein.
  • Other bezoars are composed of a variety of other substances including tissue paper and polystyrene foam products such as cups.

Phytobezoar: Phytobezoars are the most frequently observed type and account for approximately 40% of the total number of reported bezoars [2].

Phytobezoar is a trapped mass in the gastrointestinal system, that consists of components of indigestible vegetable material, most commonly from pulpy fruits, orange pits, seeds, roots or leeves [3].

Usually a single mass is found but in rare cases multiple masses can also be found.

Symptoms associated with phytobezoar are: nausea, vomiting, abdominal pain, bleeding, gastric outlet.

The bezoarian formationis secondary to:

  • Medical conditions that decrease motility in the stomach (gastroparesis)
  • Prior gastric surgery
  • Decrease of gastric acid secretion/acidity
  • Dysphagia (due to loss of teeth, poorly fitting dentures or difficulty in chewing the food properly)
  • Weight loss

Diagnosys [4]:

  • X-rays
  • CT scan
  • Abdominal ultrasound
  • Endoscopy

Treatment:

Phytobezoar can be treated either medically or surgically. Medical approach consists in administering a large amount of oral liquids in association with antispasmodic agents in case of little bezoar with no signs of bowel obstruction.

Another kind of  treatment for phytobezoar removal consists in using endoscopic approach or extracorporeal lithotripsy.

The risk of using medical treatment is that the procedure may be uncomplete and can expose the patient to iatrogenic complications such as oesophageal-gastric injuries (perforations, bleeding tear, haematoma) or intestinal obstruction due to distal migration of daughter fragments.

Surgical treatment of bezoars is eventually performed by removing the same during gastrostomy and/or enterotomy [5].

Complications: If not treated it may cause gastric ulcers, bleeding, intestinal damage or perforation and bowel obstruction.

Meckel diverticulum (MD): This congenital diverticulum is a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalo-mesenteric duct (also called the vitelline duct or yolk stalk) that ends with a completely blind sac at the ileal level. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms [6].

Most of the population with DM are asymptomatic.

Most common symptoms are rectal painless bleeding, intestinal obstructions, volvulus and intussusception. Occasionally DM may present with acute appendicitis symptoms. It can also present severe epigatsric pain [7].

Diagnosys:

  • CT scan
  • Angiography
  • Abdominal ultrasound
  • Accidentally by laparoscopy
  •  

Surgical treatment[8]

Frequent complications are rappresented by: Haemorrhage, intestinal obstruction, diverticulitis, umbelical anomalies, neoplasm.

Small Bowel obstruction due to a phytobezoar in a MD is rare (only few cases have been reported in litterature) [9].

The clinical assestment on its own might not be enough to get a correct diagnosis so it is mandatory to arrange several radiological investigations.

CT scan is useful to localize the bezoar as well as to identify bowel obstruction and complications such as perforation.

In the present report the phytobezoar the cause of formation of  bezoar could be due to the relationship between alimentary habits, concomitant presence of MD and prior abdominal surgery for intussusception [10] [11].

From the data obtained by litterature emerges that the possible presence of DM, moreover associated to prior abdominal surgery, predisposes to the formation of phytobezoar and intestinal obstruction [9].

CONCLUSION

A patient with abdominal pain, with previous abdominal surgery, difficulty in chewing, diet rich in fibers and/or delayed gastric emptying comes to their attention; clinicians may suspect that are facing a case of phytobezoar.

Phytobezoar  small bowel obstructions on diverticular malformation and previous gastric surgery are rare clinical events and require prompt and drastic treatment to avoid serious complications, even fatal [2] [12].

The timeliness of diagnostics to be carried out in the emergency room and the collaboration with the specialist surgeon are fundamental for an appropriate and rapid patient care in order to prevent serious complications.

References

[1]Cifuentes Tebar J, Robles Campos R, Parrilla Paricio P, Lujan Mompean JA, Escamilla C, Liron Ruiz R, Pellicer Franco EM. Gastric surgery and bezoars. Dig Dis Sci. 1992 Nov;37(11):1694-6. doi: 10.1007/BF01299861. PMID: 1425068.
[2]Bini R, Quiriconi F, Tello A, Fusca M, Loddo F, Leli R, Addeo A. Phytobezoar in Meckel’s diverticulum: A rare cause of small bowel obstruction. Int J Surg Case Rep. 2012;3(5):161-3. doi: 10.1016/j.ijscr.2012.01.006. Epub 2012 Feb 3. PMID: 22382033; PMCID: PMC3316763.
[3]Chen JH, Chen KY, Chang WK. Intestinal obstruction induced by phytobezoars. CMAJ. 2010 Nov 23;182(17):E797. doi: 10.1503/cmaj.090316. Epub 2010 Jul 19. PMID: 20643839; PMCID: PMC2988565.
[4]Frazzini VI Jr, English WJ, Bashist B, Moore E. Case report. Small bowel obstruction due to phytobezoar formation within Meckel diverticulum: CT findings. J Comput Assist Tomogr. 1996 May-Jun;20(3):390-2. doi: 10.1097/00004728-199605000-00012. PMID: 8626897.
[5]Fagenholz, Peter J, and Marc A de Moya. “Laparoscopic treatment of bowel obstruction due to a bezoar in a Meckel’s diverticulum.” JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 15,4 (2011): 562-4. doi:10.4293/108680811X13176785204607
[6]Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr;24(2):565-87. doi: 10.1148/rg.242035187. PMID: 15026601.
[7]Soltero MJ, Bill AH. The natural history of Meckel’s Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel’s Diverticulum found in King County, Washington, over a fifteen year period. Am J Surg. 1976 Aug;132(2):168-73. doi: 10.1016/0002-9610(76)90043-x. PMID: 952346.
[8]Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ 3rd. Surgical management of Meckel’s diverticulum. An epidemiologic, population-based study. Ann Surg. 1994 Oct;220(4):564-8; discussion 568-9. doi: 10.1097/00000658-199410000-00014. PMID: 7944666; PMCID: PMC1234434.
[9]Hussein, Bassem Abou et al. “Phytobezoar impaction in a Meckel’s diverticulum; a rare cause of bowel obstruction: Case report and review of literature.” International journal of surgery case reports vol. 30 (2017): 165-168. doi:10.1016/j.ijscr.2016.10.070
[10]W. W. e. Morris PJ, Foreign bodies. In: Oxford Textbook of Surgery, 2nd ed., Oxford: Oxford University Press, 2000.
[11]Van de Steeg LH, Postema RR. Sinaasappelileus bij een Meckel-divertikel [Ileus due to oranges in Meckel’s diverticulum]. Ned Tijdschr Geneeskd. 2012;156(46):A5353. Dutch. PMID: 23151334.
[12]Pujar K, Anupama et al. “Phytobezoar: a rare cause of small bowel obstruction.” Journal of clinical and diagnostic research : JCDR vol. 7,10 (2013): 2298-9. doi:10.7860/JCDR/2013/7248.3504
A rare case of complete pancreatic fracture in blunt abdominal trauma

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.[1] 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. [5]

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) [6]. Frequent trauma related sports: A patient reported trauma during a rugby game [7], another during a football match for a trauma with a knee [8], an accidental fall from the horse in jumping an obstacle during a horse event [9], one during a ski session [10], A patient reported a safety belt trauma [11] and onother one patient reported a fracture of the pancreas following an aggression [12].

DIAGNOSYS

  • 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[21]. 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 [22]. 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[23]
  • 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 [24]. 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[25].
  • 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). [14] The most used classification is the one proposed by American Association for the Surgery of Trauma (AAST) that includes five different Grade of seriousness. [26] (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:[27]

  • 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.[28]

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.[29]

BIBLIOGRAPHY

[1] World J Gastroenterol  2013 December 21; 19(47): 9003-9011

Pancreatic trauma: A concise review

Uma Debi, Ravinder Kaur, Kaushal Kishor Prasad, Saroj Kant Sinha, Anindita Sinha, Kartar Singh

[2] Akhrass R, Yaffe MB, Brandt CP, et al. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. 1997; 63:598–604. [PubMed: 9202533]

[3] Jobst MA, Canty TG Sr, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg. 1999; 34:818–23. [PubMed: 10359187]

[4] Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children. J Trauma. 1997; 42:1097–100. [PubMed: 9210548]

[5] “Pancreatic Trauma”

Sagar Dave,  Shawn London

[6] Traumatic Transection of Pancreas at the Neck: Feasibility of Parenchymal Preserving Strategy. Doley RPYadav TDKang MDalal AJayant MSharma RWig JD. (CITATO)

[7] Case Rep Gastroenterol. 2008 Jan 29;2(1):22-6. doi: 10.1159/000112919.

“Delayed presentation of isolated complete pancreatic transection as a result of sport-related blunt trauma to the abdomen.”

Healey AJDimarakis IPai MJiao LR.

[8] JOP. 2011 Jan 5;12(1):47-9.

Traumatic transection of the pancreas. A case of delayed presentation.

Levine RA1, Bank MA.

[9] Ann Surg. 1972 Jul;176(1):16-8.

The use of pancreatogastrostomy after blunt traumatic pancreatic transection: a complete and efficient operation.

Strauch GO.

[10] [An isolated complete fracture of pancreas due to skiing trauma. Integrated imaging in a case].

Berletti R1, Cavagna E, Carubia G, Schiavon F, Tedeschi U

[11] Acta Chir Belg. 2017 Jun;117(3):196-199. doi: 10.1080/00015458.2016.1242216. Epub 2016 Oct 13.

“A traumatic pancreatic transection despite a child safety seat”

Belyaev O1, Tcholakov O2, Uhl W1.

[12] Chirurgia (Bucur). 2014 Jan-Feb;109(1):123-7.

A case report of pancreatic transection by blunt abdominal trauma.

Braşoveanu V, Bălescu I, Anghel C, Barbu I, Ionescu M, Bacalbaşa N.

[13] Ulus Travma Acil Cerrahi Derg. 2004 Apr;10(2):138-40.

“An isolated complete pancreatic fracture primarily diagnosed by ultrasound.”

Kantarci F1Gürses BAlbayrak RAksoy SHKurugoglu SMihmanli I.

[14] Tidsskr Nor Laegeforen. 2017 Sep 18;137(17). doi: 10.4045/tidsskr.16.0888. Print 2017 Sep 19. “Blunt pancreatic injury in children.”

Antonsen IBerle VSøreide K.

[15] J Pediatr Surg. 2016 Sep; 51(9): 1526–1531.

“Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank”

Brian R. Englum, Brian C. Gulack, Henry E. Rice, John E. Scarborough, and Obinna O. Adibe

[16] Int J Legal Med. 2001 Oct;115(2):72-5.

Complete transection of the pancreas due to a single stamping injury: a case report.

Higashitani K1, Kondo T, Sato Y, Takayasu T, Mori R, Ohshima T.

[17] J Pediatr Surg. 2009 Feb;44(2):455-8. doi: 10.1016/j.jpedsurg.2008.09.026.

Early management of traumatic pancreatic transection by spleen-preserving laparoscopic distal pancreatectomy.

Nikfarjam M1, Rosen M, Ponsky T

[18] Chir Ital. 2005 Jan-Feb;57(1):109-13.

Traumatic rupture of the pancreatic isthmus complicated by concomitant rupture of the duodenum and right kidney.

Campagnoni AP1, Cossard D, Biandrate F, Piccolini M, Francia L, Ambrosino G, Zadra FM, Rosa C, Battaglia A, Pandolfi U.

[19] J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):321-3. doi: 10.1089/lap.2007.0103.

Management of traumatic complete pancreatic fracture in a child: case report and review of literature.

Leva E1, Huscher C, Rode H, Fava G, Napolitano M, Maestri L, Pansini A, Cocozza E, Numanoglu A, Prada A, Sortino G, Pansini L.

[20] Ugeskr Laeger. 1997 Aug 11;159(33):4989-90.

Pancreatic fracture diagnosed by ultrasound

Bang N1, Bentzon N.

[21] Greenlee T, Murphy K, Ram MD. Amylase isoenzymes in the evaluation of trauma patients. Am Surg 1984; 50: 637-640 [PMID: 6210005]

[22] Jeffrey RB, Laing FC, Wing VW. Ultrasound in acute pancreatic trauma. Gastrointest Radiol 1986; 11: 44-46 [PMID: 3510932]

[23] Catalano O, Lobianco R, Sandomenico F, Mattace Raso M, Siani A. Real-time, contrast-enhanced sonographic imaging in emergency radiology. Radiol Med 2004; 108: 454-469 [PMID: 15722992]

[24] Gupta A, Stuhlfaut JW, Fleming KW, Lucey BC, Soto JA. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics 2004; 24: 1381-1395 [PMID: 15371615]

[25] Jeffrey RB, Federle MP, Crass RA. Computed tomography of pancreatic trauma. Radiology 1983; 147: 491-494 [PMID: 6836127]

[26] J Trauma. 1990 Nov;30(11):1427-9.

“Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum.”

Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG

[27] J Comput Assist Tomogr. 21 (2): 246-50.

CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation.

Wong YC, Wang LJ, Lin BC et-al.

[28] Aggiornamenti diagnostico-terapeutici: traumi del pancreas

M. Nacchiero – R. Marzaioli – D. Iusco
Chirurgia Generale IV Università – Policlinico – Bari – Direttore Prof. M. Nacchiero

[29] Fisher M, Brasel K. Evolving management of pancreatic injury. Curr Opin Crit Care 2011; 17: 613-617 [PMID: 21986464 DOI: 10.1097/MCC.0b013e32834cd374]

IEMIG on Press

IEMIG inizia a muovere i primi passi proiettandosi all’ esterno delle mura ospedaliere- Il senso di responsabilità degli operatori sanitari verso la comunità e il senso di responsabilità della comunità laica verso un corretto utilizzo delle strutture sanitarie inizia a muovere i primi passi

https://www.lanazione.it/prato/cronaca/mettetevi-comodi-lezioni-di-pronto-soccorso-1.6048061

ARE YOU LOW ENERGY? WE HAVE A SOLUTION

 

pile

Battery ingestion in a special population: the prisoners. Principles of diagnosis and management,

Un detenuto , forse a corto di energia, deglutisce pile stilo. Un caso clinico nel Pronto soccorso Di Prato ( cca 90.000 accessi anno) nel cui comprensorio è presente un carcere di massima sicurezza.

clicca sul link sottostante Pile stilo ingestion last  

by Enrica Cecchi & Alessio Baldini

Emergency Department, USL4 Prato, Italy

Sospetta Sindrome di Kounis in pazienti trattati con amoxicillina o amoxicillina/acido clavulanico

   A cura di

   Cecchi Enrica, Lombardi Niccolò, Baldini Alessio, Rimoli Francesco, Vannacci Alfredo

  Lo sapevate che esiste anche una angina allergica?

   Di seguito viene riportata una serie di casi clinici che dall’inizio sembravano aver poco da spartire …..

        con il cuore!!  clicca qui sotto per scaricare l’articolo Case Series

Case Series – Sindrome di Kounis

SINDROME EPATO-RENALE (HRS): DAL “BEDSIDE” ATTRAVERSO IL “BEING AWARE” FINO AL “TAKE CARE”

 A cura di

Enrica Cecchi, MD, Dip. Pharmacol. e Alessio Baldini, MD

DEA USL 4 Prato, Italy

Molte volte il pronto soccorso rappresenta un osservatorio privilegiato di patologia complesse che tuttavia possono avere esordi insidiosi , insidiosi per esordio clinico, per la difficoltà di raccolta dei dati anamnestici.

Il caso clinico presentato in questo articolo trae spunto da un paziente che presentava difficoltà di raccolta dei dati anamnestici pur presentando sin dall’inizio un indice di complessità elevato, tanto da richiedere i letti di sub intensiva proprio del pronto soccorso.

clicca qui per leggere del caso clinico sulla  SINDROME Epato-renale

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