Traumatic transection of the intrapancreatic common bile duct due to blunt injury: a case report and literature review

Abstract

An N-year-old previously healthy man was brought by the Emergency Medical Team to our hospital, an hour after being beaten up by a gang of young men. He had been beaten all over his body including several blows to his abdomen. He was conscious (Glasgow Coma Scale 13), although agitated. Vital signs were, heart rate 116 beats/ min and BP 110/‘70 mmHg. His only complaint was of diffuse abdominal pain. On physical examination, ecchymoses and contusions were absent, no penetrating wounds were present and a small laceration of 3 cm on the lower lip was noted. Lung examination was normal. The abdomen was flat with diffuse tenderness in all four quadrants. There were no other abnormalities. Because of his intoxicated and agitated state the patient was sedated and anaesthetized and an elective intubation was performed. At this point a nasogastric tube was inserted and brought up 300 cm3 of coffee-ground material. A urinary catheter was inserted with good urine output and no signs of haematuria. X-Rays of the chest, pelvis and cervical spine were normal. Computed tomography (CT) of the head revealed findings of a small frontal intracerebral bleed. There were no signs of increased intracranial pressure (Figure 2). CT of the abdomen showed free fluid in the abdominal cavity extending from the subhepatic region to the pelvis. The spleen and liver were intact (Figure 2). Because of the intact spleen and liver and the presence of free fluid in the abdomen, the abdomen was explored. A large subcutaneous haematoma was observed in the epigastric regtion, and 500 cm3 of fresh blood was aspirated from the peritoneal cavity. A large haematoma was detected in the retroperitoneum extending from the duodenum down to the sacral region. A blotch of bile was found staining the upper portion of the first part of the duodenum. A Cattell procedure was performed and the duodenum was mobilized using the Kocher manoeuvre, at which time a blowhole of 2 mm by 3 mm was observed in the duodenum, approximately in the middle of the 1st to 2nd division of the organ. Exploration of the common bile duct showed an intact duct. During the procedure bile was noticed to exude from