Presentation
Bilious vomiting. Tender abdomen.
Patient Data
Initial XR is unremarkable
Nonspecific bowel gas pattern. No evidence of pneumoperitoneum or bowel obstruction.
Query intussusception
No evidence of intussusception.
Large complex, septated collection or mass throughout the abdomen and around the left kidney, suggestive of hemoperitoneum.
The appearances of the liver, kidneys and spleen are normal.
Laparotomy showed hemoperitoneum and something dark purple noted in the retroperitoneum. Lipase 1368. Hemoglobin 91 dropping from 131.
Oral contrast was not administered. Difficult interpretation due to a low-dose scanning technique, widespread subcutaneous and intra-abdominal edema, as well as lack of oral contrast.
FINDINGS:
Enteric catheter tip lies within the proximal duodenum.
Widespread subcutaneous and intra-abdominal fat stranding and edema (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 edema 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 (arrows), peripancreatic edema, 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, metaphyseal corner fracture, rib fractures, subdural hematomas) are becoming infrequent.
Pancreatic transection and rupture of lymphatics are known to occur in the context of non-accidental injury.
Of note, a third of all post traumatic pancreatitis is abuse related.
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