Pancreatic transection - possible non-accidental injury

Case contributed by Dr Tim Luijkx

Presentation

Bilious vomiting. Tender abdomen.

Patient Data

Age: 2 years
Gender: Male
X-ray

Initial radiograph is unremarkable

Nonspecific bowel gas pattern. No evidence of pneumoperitoneum or bowel obstruction.

Ultrasound

Ultrasound requested querying intussusception

No evidence of intussusception.

Large complex, septated collection or mass throughout the abdomen and around the left kidney, suggestive of haemoperitoneum.

The appearances of the liver, kidneys and spleen are normal.

Laparotomy showed haemoperitoneum and something dark purple noted in the retroperitoneum. Lipase 1368. Haemoglobin 91 dropping from 131. 

CT

CT 2 days post-operative

Oral contrast was not administered. Difficult interpretation due to a low-dose scanning technique, widespread subcutaneous and intra-abdominal oedema, as well as lack of oral contrast.

FINDINGS:

Enteric catheter tip lies within the proximal duodenum.
Widespread subcutaneous and intra-abdominal fat stranding and oedema (both intraperitoneal, and retroperitoneal). Multiple locules of free gas in the anterior abdomen. Evidence of subcutaneous emphysema in the left anterior abdominal wall in keeping with recent surgery.

A 1.5 cm defect is present in the body of the pancreas having the appearance of transection. Peripancreatic oedema is present anteriorly predominantly in the lesser sac with no discrete collection.

The liver, spleen, adrenal glands and kidneys appear unremarkable.

A moderate amount of free fluid amongst the small bowel loops.

There is a left-sided pleural effusion. There is minor subsegmental left lower lobe collapse. No bony lesions identified

IMPRESSION:

Likely pancreatic transection, peripancreatic oedema, free intraperitoneal fluid and left pleural effusion.

Case Discussion

The nature of the injury together with a history lacking a good explanation for it is concerning for non-accidental injury.

At 2 years of age a child becomes too big to be shaken and the typical injuries associated with this (among others bucket handle fractures, rib fractures, subdural haematomas) are becoming infrequent. 

Pancreatic transection and rupture of lymphatics are known to occur in the context of non-accidental injury.

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Case information

rID: 56579
Case created: 10th Nov 2017
Last edited: 16th Nov 2017
System: Paediatrics
Inclusion in quiz mode: Included

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