Traumatic renal devascularisation and pancreatic laceration
Unrestrained passenger in motor vehicle accident. Severe back pain and upper abdominal pain.
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Scans were performed following IV contrast (Omnipaque 350) including delayed images.
There is no perfusion of the left kidney. The left renal artery demonstrates normal opacification within its proximal 7 mm. There is however immediate truncation of the artery at a point of retroperitoneal hematoma. This hematoma lies immediately posterior to a laceration of the body of the pancreas. There are only small contrast opacified vessels identified within the left kidney. Within the posterior aspect of the left kidney, there is a region of apparent contrast extravasation that demonstrates increased spread and size increase on the delayed scan. Remote from the left renal hilum, no large left perinephric collection. On the delayed phase, there is minor contrast opacification of the left renal collecting system without evidence of injury to the left collecting system.
The right kidney demonstrates compensatory increased perfusion. The right renal artery has an unremarkable appearance. No evidence of traumatic injury to the right collecting system.
There is a laceration through the body of the pancreas that extends completely from its anterior to posterior borders. There is also an 11 mm laceration through the medial border of the spleen that does not extend to the splenic hilum. There is an associated retroperitoneal hematoma/collection that lies within the lienorenal and gastrosplenic ligaments, as well as lying superior to the pancreas. No free intraperitoneal fluid or gas.
There is a laceration through the lateral segments of the left lobe of the liver. The hepatic veins, porta hepatis and intrahepatic IVC are not involved. Bilateral adrenal glands have an unremarkable appearance. Previous cholecystectomy. Common bile duct measures 8 mm. The ostia of the celiac trunk, SMA and IMA are unremarkable. The small and large bowel enhance normally, with no abnormal regions of abnormal wall thickening identified. Retroverted uterus. No pelvic fracture.
No lumbar spine fracture. Failure of fusion of the posterior elements of S1 noted.
1. Devascularisation of the left kidney secondary to transection of the left renal artery. Suspicion for active hemorrhage within the posterior aspect of the left kidney.
2. Pancreas body laceration, possibly transection, at risk for pancreatic duct injury, especially given the low density of the retroperitoneal collection.
3. Splenic and left lobe of liver lacerations. No active contrast extravasation identified at these lacerations. There is an associated retroperitoneal hematoma/collection that tracks into the lienorenal and gastrosplenic ligaments.
4. Small right hemothorax.
There were also minimally displaced right T7 to T9 transverse process fractures, and a small fracture of the right posterolateral superior corner of the T10 vertebral body (not shown).
The patient proceeded to laparotomy. The left renal artery was almost completely transected, with only a small bridging intimal flap remaining. The pancreatic body was transected with injury to the main pancreatic duct. A left total nephrectomy, partial pancreatectomy and splenectomy was subsequently performed.
The pancreas is uncommonly injured in blunt trauma. When injured however, it is invariably associated with other visceral injury. The pancreatic body is the most common site for traumatic injury.