Abstract
IntroductionA pancreatic pseudocyst is a common sequela of severe acute pancreatitis. Commonly, it presents with abdominal pain and a mass in the epigastrium several weeks after the acute episode and can be managed conservatively, endoscopically or surgically. We report a patient with a pancreatic pseudocyst awaiting endoscopic therapy who developed a life-threatening complication following a rather innocuous trauma to the abdomen.Case presentationA 23-year-old Asian male student presented as an emergency with an acute abdomen a week after a minor trauma to his upper abdomen. The injury occurred when he was innocently punched in the abdomen by a friend. He experienced only moderate discomfort briefly at the time. His past medical history included coeliac disease and an admission four months previously with severe acute pancreatitis. He was hospitalized for 15 days; his pancreatitis was thought to be due to alcohol binge drinking on weekends. Ultrasound scanning showed no evidence of gallstone disease. Five days after the trauma, he became anorexic, lethargic and feverish and started vomiting bilious content. Seven days post-trauma, he presented to our emergency department with severe abdominal pain. An emergency laparotomy was performed where a transverse linear duodenal laceration was found at the junction of the first and second part of his duodenum, with generalized peritonitis. His stomach and duodenum were stretched over a large pancreatic pseudocyst posterior to his stomach. It was postulated that an incomplete duodenal injury (possibly a serosal tear) occurred following the initial minor trauma, which was followed by local tissue necrosis at the injury site resulting in a delayed presentation of generalized peritonitis.ConclusionThis is the first reported case of a traumatic duodenal laceration following minor blunt trauma in the presence of a large pancreatic pseudocyst. Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in a significant duodenal injury. In the presence of a large pseudocyst, however, the stretching of the duodenum over the pseudocyst had probably predisposed the duodenum to this injury. Patients awaiting therapeutic interventions for their pancreatic pseudocysts should be warned about this unusual but life-threatening risk following minor blunt abdominal trauma.
Highlights
A pancreatic pseudocyst is a common sequela of severe acute pancreatitis
Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in a significant duodenal injury
Minor blunt abdominal trauma in a normal healthy adult would not be expected to result in any significant duodenal injury
Summary
Acute pancreatitis is a common condition presenting to general surgical and medical wards. The majority resolve spontaneously [9] and treatment is usually reserved for those which are symptomatic, larger than 6 cm and those which do not reduce in size during a sixweek observation period [9,10] This is the first reported case of a duodenal laceration following minor blunt abdominal trauma in the presence of a large pancreatic pseudocyst. The absence of any external bruising to the abdominal wall on examination suggests that the blow was unlikely to have been severe, as we would expect this to occur with a severe blow In this case, we postulated that the stretching of the duodenum over the large pancreatic pseudocyst had predisposed the duodenal wall to such an injury. Competing interests The authors declare that they have no competing interests
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