Blunt trauma abdomen with pancreatic laceration

In our last admission day, a 23 year old male patient presented to the emergency with a history of blunt trauma abdomen 4 days back. He was riding a motorcycle (without helmet of course) when he skidded and fell down. He was previously admitted at an outside facility where he was managed conservatively. When he presented to us, he was conscious, alert and cooperative, without any significant external injuries. He had no pallor, jaundice, cyanosis, clubbing or edema. His pulse was 118/min, BP-122/70 mmHg, RR – 26/min and was afebrile. His abdomen was distended, tense and tender. Hepatic dullness was not obliterated and IPS was absent. His chest X-ray and straight X-ray abdomen did not show any significant abnormality.

He had CT scan of the whole abdomen done two days after the injury which showed grade III hepatic laceration involving segment VII and VIII and laceration of the pancreas at the body along with hemoperitoneum. We did not have access to emergency ultrasound so an abdominal tap was done which revealed presence of blood. The visiting surgeon was informed and a decision was taken to undertake emergency laparotomy for the patient. Then there was a sudden significant development in the patient. His SpO2 in room air was found to be 83%. It debated whether to do a repeat X-ray or to do a pleural tap. It was decided to do b/l pleural tap which revealed b/l hemothorax.

 

 

The patient was taken to the operation theatre and before laparotomy, b/l chest drains were put in. About 500 ml of blood came from each drain following the SpO2 rose to 97%. We then proceeded to laparotomy. The abdomen was opened by midline incision. On opening, the abdomen, blood was seen within the abdominal cavity which was sucked out. There was an estimated 2 liters of blood within the abdominal cavity. On exploring, the infracolic compartment was found to be normal. A 10 cm laceration was seen in the antero-superior surface of liver with a parenchymal depth of 1 cm. there was no active bleeding from it was decided to leave it as such. There was extensive saponification in the supracolic compartment . The lesser sac was entered by dividing the gastrocolic ligament. On entering the lesser sac, dark coloured serous fluid came out which was sucked out. there was extensive saponification along the body of the pancreas and the pancreas was highly friable. The exact site of the pancreatic laceration could not be identified. The spleen and the duodenum was found to be normal. It was decided to put a drain in the lesser sac and close the abdomen. A feeding jejunostomy was done to maintain nutrition in the post-operative period as possible pancreatic fistula was anticipated.

The patient is presently in 4^th post-op day with a high leucocyte count – 21000/mm3 and the output from the drain in the lesser sac is about 75ml in 24 hrs. Both the chest drains have become non-functional but the patient is having tachyapnea. He is scheduled for a CT thorax and upper abdomen after 2 days. Feeding through FJ has been started.