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What Do These Ultrasound Reports Post Abdominal Trauma Indicate?
Question: My son met with an accident.Blunt abdomen trauma on 26/01/2006.
Exploratory laprotomy showed:
1) Haematoma in mesocolon - removed.
2) Transverse colon perforation - Resection anastomosis done.
3) Tear in superior mesentric vein - repaired.
Patient was discharged on 08/02/06 following regressal of symptoms and signs.
Readmitted on 11/02/06 for abdominal pain and vomiting- treated conservatively and discharged on 16/02/06.
Readmitted on 22/02/06 for pain in left side of abdomen, anorexia, constipation.
Ct Scan done on 27/02/06 revealed:
1) Focal areas in liver showing differential enhancement as compared to the normal liver parenchyma. Vascular aetiology could be the cause. Contusions is less likely differential diagnostic possibility.Filling defect is seen in the right branch of portal vein, which is supplying the posterior hepatic segments of right lobe. This could be repesenting intraluminal segmental portal venous thrombosis.
2) Partial superior mesentric vein thrombosis.
3) Pancreatic head injury.
4) Significant intra-abdominal collections in the extrasplenic omentum and also along the lesser curvature of the stomach. Lesser sac collections are also apparent with ascites.
Further investigation reports revealed left pleural effusion with acute pancreatitis ( S. Amylase - 1,62,000 IU/L ) due to pseudocyst.
Shifted for gastrocystostomy on 06/03/06.
EUS guided drainage of the pancreatic pseudocyst on 07/03/06.Two 7 Fr. pigtail stents were placed in the cyst cavity for drainage.
On 09/03/06, Dudenoscopy revealed a normal papilla. The pancreatic duct was opacified through major papilla. It showed a normal duct upto the mid body beyond which there was a leak into the cyst cavity. The duct in the tail could not be opacified. A pancreatic papillotomy was performed and a 7 Fr. tapered stent was placed through the PD into the cyst cavity.
EUS guided drainage of the a second pancreatic pseudocyst which was seen later on 13/03/06.Two 7 Fr. pigtail stents were placed in the cyst cavity for drainage.
Discharged on 03/04/06.
Stents removed on 08/05/06.
Patient readmitted on 10/05/06 for pain in abdomen and vomiting.Exploratory laprotomy done on 17/05/06, revealed multiple dense adhesion obstruction around jejunum - adhesiolysis done. Discharged on 29/05/06.
Patient readmitted on 06/07/06 for pain in abdomen and vomiting.Imaging of the abdomen revealed multiple fluid levels. Treate conservatively and responded well. Discharged on 14/07/06.
Fortnightly/monthly follw up USGs revealed - visualised pancrea appears normal in size and ecotexture. Pancreatic duct is getting dilated in body and tail and measures from 4mm earlier to 5.50mm now. No cyst or free fluid seen.
Later every year check-ups have been done and no major findings except every time fatty infiltration of lever and higher total bilirubin (upto 2 mg/dl). Main pancreatic duct also became gradually normal (max upto 02 mm). Latest check-up done this week. Diagnosis is Borderline Hepatomegaly with Gde II fatty lever (lever size 15.6 cm, normal in position, outline and increased echtexture, no focal lesion or IHBR dilation seen, All other things normal including MPD ). Total cholesterol - 110 mg/dl, Triglycerides-36 mg/dl, VLDL-07 mg/dl, HDL-40 mg/dl,LDL-63 mg/dl, Total bilirubin-3.0 mg/dl, Conjugated Bilirubin-0.6 mg/dl,Total protein-6.5 g/dl, Albumin-4.0 g/dl, Globulin-2.5 g/dl, AG Ratio-1.6:1, SGOT-22 IU/L, SGPT-20 IU/L, Alk phosphate-54 IU/L
Exploratory laprotomy showed:
1) Haematoma in mesocolon - removed.
2) Transverse colon perforation - Resection anastomosis done.
3) Tear in superior mesentric vein - repaired.
Patient was discharged on 08/02/06 following regressal of symptoms and signs.
Readmitted on 11/02/06 for abdominal pain and vomiting- treated conservatively and discharged on 16/02/06.
Readmitted on 22/02/06 for pain in left side of abdomen, anorexia, constipation.
Ct Scan done on 27/02/06 revealed:
1) Focal areas in liver showing differential enhancement as compared to the normal liver parenchyma. Vascular aetiology could be the cause. Contusions is less likely differential diagnostic possibility.Filling defect is seen in the right branch of portal vein, which is supplying the posterior hepatic segments of right lobe. This could be repesenting intraluminal segmental portal venous thrombosis.
2) Partial superior mesentric vein thrombosis.
3) Pancreatic head injury.
4) Significant intra-abdominal collections in the extrasplenic omentum and also along the lesser curvature of the stomach. Lesser sac collections are also apparent with ascites.
Further investigation reports revealed left pleural effusion with acute pancreatitis ( S. Amylase - 1,62,000 IU/L ) due to pseudocyst.
Shifted for gastrocystostomy on 06/03/06.
EUS guided drainage of the pancreatic pseudocyst on 07/03/06.Two 7 Fr. pigtail stents were placed in the cyst cavity for drainage.
On 09/03/06, Dudenoscopy revealed a normal papilla. The pancreatic duct was opacified through major papilla. It showed a normal duct upto the mid body beyond which there was a leak into the cyst cavity. The duct in the tail could not be opacified. A pancreatic papillotomy was performed and a 7 Fr. tapered stent was placed through the PD into the cyst cavity.
EUS guided drainage of the a second pancreatic pseudocyst which was seen later on 13/03/06.Two 7 Fr. pigtail stents were placed in the cyst cavity for drainage.
Discharged on 03/04/06.
Stents removed on 08/05/06.
Patient readmitted on 10/05/06 for pain in abdomen and vomiting.Exploratory laprotomy done on 17/05/06, revealed multiple dense adhesion obstruction around jejunum - adhesiolysis done. Discharged on 29/05/06.
Patient readmitted on 06/07/06 for pain in abdomen and vomiting.Imaging of the abdomen revealed multiple fluid levels. Treate conservatively and responded well. Discharged on 14/07/06.
Fortnightly/monthly follw up USGs revealed - visualised pancrea appears normal in size and ecotexture. Pancreatic duct is getting dilated in body and tail and measures from 4mm earlier to 5.50mm now. No cyst or free fluid seen.
Later every year check-ups have been done and no major findings except every time fatty infiltration of lever and higher total bilirubin (upto 2 mg/dl). Main pancreatic duct also became gradually normal (max upto 02 mm). Latest check-up done this week. Diagnosis is Borderline Hepatomegaly with Gde II fatty lever (lever size 15.6 cm, normal in position, outline and increased echtexture, no focal lesion or IHBR dilation seen, All other things normal including MPD ). Total cholesterol - 110 mg/dl, Triglycerides-36 mg/dl, VLDL-07 mg/dl, HDL-40 mg/dl,LDL-63 mg/dl, Total bilirubin-3.0 mg/dl, Conjugated Bilirubin-0.6 mg/dl,Total protein-6.5 g/dl, Albumin-4.0 g/dl, Globulin-2.5 g/dl, AG Ratio-1.6:1, SGOT-22 IU/L, SGPT-20 IU/L, Alk phosphate-54 IU/L
Brief Answer:
Elevated bilirubin is due to ductal stricture.Please upload latest scan.
Detailed Answer:
Hello, Sir.
I understand your concern.
I have through your query in detail.
Coming straight to the point- Pancreatic injuries are difficult to manage, owing to the unforgiving nature of the pancreas, both for missed injury and after a major emergency operative intervention. and are known to cause frequent complications as evident in your case.
Those involving the ductal system often cause an elevation in bilirubin levels.
Since your son had pseudocysts twice (7th and 13th), the likelihood of the another pseudocyst is high.
Based on the scan reports of the past and the present, I suspect a pancreatic ductal stricture most likely in the body and tail region.
This can cause elevations of the serum bilirubin-3mg % as in your case.
I request you to upload the recent CT scan report in full for personal evaluation.
Please note Ultrasound is efficient enough to document pancreatic anatomy and is thus unreliable in follow up.
You have earlier mentioned pancreas is normal (including MPD). I would like to recheck it. There is a disparity between the scan and lab findings.Even in spite of normal MPD, strictures can occur elsewhere in the body and tail region of the pancreas.
To clarify this disparity, the best investigation which I can suggest you is MRCP.
This can accurately diagnose the ductal architecture.
The best treatment at this moment is the removal of the body and tail region of the pancreas.This can largely prevent future complications of both pseudocysts and ductal stricture and dilatation.
Post your further queries if any.
Thank you.
Elevated bilirubin is due to ductal stricture.Please upload latest scan.
Detailed Answer:
Hello, Sir.
I understand your concern.
I have through your query in detail.
Coming straight to the point- Pancreatic injuries are difficult to manage, owing to the unforgiving nature of the pancreas, both for missed injury and after a major emergency operative intervention. and are known to cause frequent complications as evident in your case.
Those involving the ductal system often cause an elevation in bilirubin levels.
Since your son had pseudocysts twice (7th and 13th), the likelihood of the another pseudocyst is high.
Based on the scan reports of the past and the present, I suspect a pancreatic ductal stricture most likely in the body and tail region.
This can cause elevations of the serum bilirubin-3mg % as in your case.
I request you to upload the recent CT scan report in full for personal evaluation.
Please note Ultrasound is efficient enough to document pancreatic anatomy and is thus unreliable in follow up.
You have earlier mentioned pancreas is normal (including MPD). I would like to recheck it. There is a disparity between the scan and lab findings.Even in spite of normal MPD, strictures can occur elsewhere in the body and tail region of the pancreas.
To clarify this disparity, the best investigation which I can suggest you is MRCP.
This can accurately diagnose the ductal architecture.
The best treatment at this moment is the removal of the body and tail region of the pancreas.This can largely prevent future complications of both pseudocysts and ductal stricture and dilatation.
Post your further queries if any.
Thank you.
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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