大韓 放射線짧 쩔 會 :tt 第 27 卷 第1號 pp.120-123, 1991 J ournal of Korean Radiological Society, 27(1) 120 -123, 1991

Traumatic Pancreas Transection: CT Findings -Case Report-

Jin Wha Kang, M.D. , In Don Ok, M.D. , Hyun Ki Yoon , M .D. *

Department o[ Diagnostic Radiology , Dae Jeon Eul Ji General Hospital

〈국문초록〉

외상에 의한 훼장절단의 전산화단층 소견

대전을지병원 진단방사선과

강 진 화 • 옥 인 돈 • 윤 현 기 *

외상에 의한 훼장절단은 비 교적 드문 질환으로 복부둔상(blunt abdominal t rauma)의 1-2% 정 도에서 발생하고(1) 예후가

불량하여 조기진단이 예후에 큰 영향을 준다(2-3). 전산화단충촬영은 조기진단의 최선의 방법으로， 절단면의 확인 ， 훼장주변

지 방층의 부종， 장간맥 혈관주위의 부종， 좌측 주신막(perire na l fasc ia)의 비 후， 횡행결장간막(transve rse mesocolon) 혈종

동의 소견을 볼 수 있다 (1-4).

저자동은 교통사고에 의한 l 예 를 포함한 복부둔상에 의한 춰1 장절단 3예의 전산화단충촬영을 경험하였기에 보고하는 바

이다.

Index Words: Pancreas ‘ CT 770 ‘ 12 11

Pancreas ‘ injury 770. 411

Trauma to the pancreas is uncommon. a nd pan­

creatic injury is detected only in 1-2% ofpatients with

blunt abdomina l tra uma (1). However. the mortality

from pancreatic injury is nearly 20% and delayed

diagnosis contributes to the high mortality (2-3).

Computed tomography (CT) is the most effective im­

aging modality for pa ncreas transection. In this case

report. we describe a series of three patients with

traumatic pancreatic transection who were examin-

On physical examination abdominal tenderness . re­

bound tenderness a nd muscle guarding was detected.

Serum amylase level was 529 units. Emergent distal

pan createctom y a nd splenectomy was don e im­

m ediately after CT examination . On operation pan­

creas was transected at neck portion and surrounded

by la rge hematoma. Body and tail of the pancreas was

enlarged .

e d by abdominal CT prior to laparotomy. Case 2

Case 1 Thirty-two year old male patien t complained

severe abdominal a nd f1a nk pain after blunt trauma

Thirty-two year old female patient visite d (s treet figh t) on right f1ank area. On physical examina-

em ergency room complaining diffuse abdominal pa in t ion , tenderness and rebound tenderness was

developed after blunt abdominal trauma (street fight) . detected on right flank. Serum amylase level was 932

* 서울대 학교병원 진단방사선과학교실

., Department o[ Diagnostic Radiology. Seoul National University Hospital 이 논문은 1 990년 8월 27일 접수하여 1 990년 11 월 1 2일에 채택되었음

Received August 27 . accepted November 12. 1990

- 120 -

Jin Wha Kang, et al: Traumatic Pancreas Transection: CT Findings

Fig. 1. Case 1: Thirty-two year old female patient: CT was performed in 72 hours after blunt abdominal trauma (street fight) a. On pre-contrast CT. transection is seen at the level of the superior mesenteric artery origin (arrow). Panceras body and tail shows low density. High density fluid collection suggesting hemorrhage (asterisk) is seen in the lesser sac and lower density fluid collection is noted in left anterior pararenal space. Left anterior perirenal fascial thicken ing is a lso seen. b. On post-contrast CT . hemorrhage component (asterisk) is note d as relatively lower density compared with pre­contrast CT. Thickened left renal fascia (arrow heads) is irregularly enhan ced.

Fig.2. Case 2: Thirty-two year old male patient: CT was done within 24 hours after blunt abdominal injury (street fight) On post-contrast CT. low density vertical fracture line (a rrow) is well visualized at its neck portion. opposite to the vertebra. just left to the portal confluence. No signifi­cant fluid collection is detected.

units . Two days after emergent co mpute d

tomogra phy dista l pancreatectomy and splenectomy

was done. Pancreas was transected above the

superior mesente ric artery and was swollen.

cy room complaining severe abdominal pain

developed after traffic accident. Physical examination

findings w ere same as above two patients. One day

later abdominal CT was performed. After then distal

pancreatectomy with splenectomy was done. On

operation pancreas transection at n eck portion was

confirmed. Postoperatively abscess and hemorrhage

was d eveloped . Percutaneous needle aspiration was

tried but effective drainage was impossible because

ofthic k old blood clots. On second operation peform­

ed in twentyfour days after previous operation , ex

ploration and abscess drainage was done.

Discussion

Pancreatic injuries are relative ly uncommon , are

detected only in 1-2% of patients with blunt ab-

dominal trauma (1) , and account for only 3% to 12%

of all abdominal injuries (3) _ However , the mortality

from pancreatic injury is nearly up to 20% (2 ,3). In

our cases two had blunt abdominal injury due to

street fight and one had traffic acciden t. They were

all young age. There was no morta lity case

Case 3 Previously , the diagnosis ofpancreas transection

has been made at the time of surgery , but even then

Thirty-four year old male patient visited em ergen- the transection can be overlooked (4). The clinical

- 121-

λ韓放MUil염쏠쩍A會승t. : i$ 27 卷 第 l 號 1991

a

b

c

Fig. 3. Case 3: Thirty.four year old male patient: CT was performed within 24 hours after traffic accident. a.b.c. On post.contrast CT ciear vertical line (arrow) separating pancreatic head and neck of lower density from body and tail ofrelatively high density is detected. Low density l1uid collection is well visualized in anterior pararenal space and adjacent to the m esenteric vessels (long arrows). Left anterior perirenal fascial thickening (arrow heads) is also seen .

triad for acute pancreatic trauma is upper abdominal

pain , leukocytosis , and hyperamylasemia. These fin­

dings , however , may be partially or completely ab­

sent for several days after injury. Additionally ,

false-positive findings , especially relating to amylase

values , are not infrequent. Therefore , an imaging test

is needed to diagnose accurately significant pan­

creatic trauma soon after injury so that appropriate

treatment can be instituted. Simple abdomen or

barium study provide only indirect evidence of pan­

creatic injury such as the ‘ cut off of the duodenalloop

or colon and an increased distance between the

stomach and colon (2). Ultrasound is suitable for

diagnosing focal or generalized pancreatic enlarge­

m ent or pseudocyst but generally misses a pancreatic

fracture per se (1). Computed tomography offers an

easy way to visualize the pancreas, and the diagnosis

of transection can be made preoperatively (4). The

sensitivity of CT for diagnosing blunt injuries to the

liver and spleen is up to 95%. but the sensitivity of

CT for detecting significant pancreatic injuries is

judged to be less (1). Jeffery J r. et a l. reported two

false positive and two false negative diagnosis among

the thirteen patients with surgically proven pan­

creatic fractures. They said that too early performed

(within 12 hours after injury) CT could mask the frac­

ture line per se. and streak artifact contributed to the

false positive and false negative diagnosis (3). Jeffèry

et a l. said that emergent endoscopic retrograde

cholangiopancreatography might be required to in­

vestigate pancreatic injuries when CT findings were

equivocal or when the CT were technical inadequate

(3 ,4). And Dodds et a l. said that repeat sequences at

5mm slice thickness , repeated CT in 12-24 hours

could be helpful(l) .

CT findings of pancreatic injury are ciear fracture

line acrossing the neck of the pancreas (just to the

left ofthe mesenteric vessel). retroperitone외 f1uid col­

lection , edema around the origin of the mesenteric

artery and/or edema in the peripancreatic fat . or

thickening of the left anterior perirenal fascia .

Especially thickening of the left anterior perirenal

fascia is known to be the early warning sign when

the fracture line is not definite (1-4) . In our cases, in

addition to the fracture lines , left anterior perirenaJ

- 122-

Jin Wha Kang. et al: Traumatic Pancreas Transection: CT Findings

fascia thickening. fluid collection in lesser sac and

anterior pararenal space. edema and hematoma ad­

jascent to mesenteric vessel. focallow density of pan­

creas. and enlargement were detected.

Complication of the pancreatic fracture are

pseudocyst. hemorrhage. and abscess formation. In

our cases one patient suffered from abscess forma­

tion postoperatively.

REFERENCES

1. Dodds WJ. Taylor AJ. Erickson SJ et a l. Traumatic

Fracture of the Pancreas: CT Characteristics. Jour­

nal ofComputed Assisted Tomography 1990; 14(3):

375-378

2. Ivancev K. Mullendorff CM. Value of Computed

Tomography in Traumatic Pancreatitis in Children.

Acta Radiologica Diagnosis 1983; 24:441.443

3. Jeffery RB. Federle MP. Crass RA. Computed

Tomography ofPancreatic Trauma. Radiology 1983;

147:491.494

4 . Baker LP. Wagner EJ. Brotman S et a l. Transection

of the Pancreas. Journal of Computed Assisted

Tomography 1982; 6:411.412

- 123-