Duct-related complications of pediatric post-traumatic pancreatitis: A case report from Syria

Abstract

Introduction

Pancreatic trauma is a rare type of abdominal injury, representing only 0.3 % of pediatric trauma cases. This condition may progress to chronic pancreatitis and result in multiple complications following damage to the pancreatic duct.

Presentation of case

A 5-year-old boy presented to the hospital with abdominal pain and had a history of chronic pancreatitis following a bicycle handlebar accident one year ago. Ultrasound screening revealed the presence of abdominal ascites which was treated conservatively. Two months post-treatment, the patient developed a pseudocyst in the head of the pancreas and a right-sided pleural effusion that was treated by inserting a plastic stent into the pancreatic duct through endoscopic retrograde cholangiopancreatography (ERCP). This caused inflammation of the pseudocyst, which was eventually drained to the stomach using endoscopy. No recurrence was observed after removing the stents four weeks later.

Discussion

Invasive techniques like ERCP are necessary for some cases of pancreatic fistulas that do not respond well to conservative treatment.

Conclusion

ERCP is an effective way to diagnose and treat several duct-related complications of traumatic pancreatitis. Although ideal management of such rare conditions remains highly debatable, non-invasive strategies are preferable for pediatric patients.

Highlights

• •Blunt pancreatic trauma is rare in childhood mainly resulting from bicycle handlebar accidents.
• •Although infrequent, pediatric chronic pancreatitis may arise post-trauma, potentially damaging the main pancreatic duct.
• •Complications of pancreatic duct disruptions include pancreatic pseudocyst and fistula formation.
• •ERCP provides a plausible diagnostic and theraputic modality but still carries a risk for complications.

1. Introduction

Pediatric trauma patients rarely sustain damage to the pancreas considering its retroperitoneal protection [1]. Nevertheless, children involved in bicycle handlebar accidents are more susceptible to blunt injuries resulting from forceful collision of the pancreas against the vertebral column [2]. Such traumatic injuries are usually subtle on initial examination. Still, they may also give rise to some critical consequences including acute pediatric pancreatitis, which occasionally becomes chronic compromising the child's quality of life [3]. Despite being extremely infrequent, chronic inflammation of the pancreas may also cause injuries to the main pancreatic duct leading to the formation of pseudocysts and internal fistulas [4]. Rare incidence along with non-specific manifestations makes correct diagnosis of pancreatic duct disruptions heavily dependent on clinical suspicion [5]. Management also remains controversial, with no clear guidelines applicable to all pediatric patients [4].

To our knowledge, very few cases in pediatric literature reported developing multiple rare complications over a short time. Therefore, this article presents the unusual case of a five-year-old boy with an established history of chronic post-traumatic pancreatitis resulting in three significant duct-related complications within two months. In the report, we particularly focus on diagnosing such conditions and the successful endoscopic approach we used to treat our patient in a low-resource setting.

The work has been reported in line with the SCARE criteria [6].

2. Case presentation

A 5-year-old boy was referred to the Gastrointestinal Department for evaluation of vague abdominal pain, steatorrhea, and poor oral reception. The boy had a history of chronic pancreatitis after a bicycle handlebar accident he sustained a year ago. On physical examination, the patient appeared pale weighing about 17 kg with evident abdominal distension and no palpable masses.

Blood tests revealed elevated levels of amylase (867 IU/L) and lipase (1360 IU/L). Abdominal ultrasound (US) showed moderate to large amounts of free intraperitoneal fluid with a slightly turbid appearance. However, computed tomography (CT) with contrast injection indicated no other distinctive abnormalities. Analysis of ascitic fluid marked high values of amylase (900 IU/L) and albumin (8.8 μg/dL), while bacterial culture came back negative.

Besides fluid aspiration, treatment also included the administration of Spironolactone (0.5 mg/kg/day PO for a couple of days) along with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for pain management. We also provided intravenous fluid replacement every 6 h to compensate for electrolyte deficiencies (70 mL Ns + 280 mL 5 % Ds + KCl), alongside dietary modifications.

Two months post-treatment, the patient presented with dyspnea and shortness of breath. Chest X-ray (CXR) revealed a significant right-sided pleural effusion (Fig. 1) and aspirated fluid contained high levels of amylase (1804 IU/L) and lipase (3835 IU/L). At the same time, abdominal US demonstrated a fluid collection around the head of the pancreas measuring 117 × 1.5 × 65 mm.

Fig. 1.

Simple chest X-ray (CXR) showing significant right-sided pleural effusion.

In addition to Somatostatin infusion therapy (0.3 μg/kg/day IV) and dietary restrictions, we used ERCP to address the suspected pancreatic fistula by inserting a 5 French/ 7 cm plastic stent into the pancreatic duct (Fig. 2).

Fig. 2.

Endoscopic retrograde cholangiopancreatography (ERCP) showing the main pancreatic duct cannulation.

Two weeks later, the patient exhibited inflammatory symptoms with elevated values of serum amylase, lipase, ESR, and CRP. Further evaluation with US and CT implied infection of the pseudocyst as it rapidly became larger measuring 150 × 140 × 110 mm with cloudier contents (Fig. 3). Therefore, we added antibiotics to the treatment regimen including Vancomycin (45 mg/kg/day IV for 7 days).

Fig. 3.

Abdominal ultrasound (US) showing the large infected pseudocyst.

Eventually, the patient underwent endoscopic drainage, which involved aspiration of pus followed by irrigation with saline solution. During the procedure, we placed two plastic stents (10 French/ 5 cm and 5 French/ 10 cm) connecting the cystic cavity to the stomach (Fig. 4).

Fig. 4.

Endoscopic view of the cystic cavity with abundant purulent contents drained to the stomach.

We carefully observed the patient's response throughout the course of treatment to ensure clinical stability. As a result, he was discharged a week later in a generally good health with recommendations for regular out-patient follow-up visits. We removed the stents after 4 weeks as findings remained normal on repeat US screenings. Serum amylase and lipase levels shortly returned to normal range. Subsequently, all signs and symptoms subsided and the patient's weight improved.

3. Discussion

Pancreatic trauma is an exceptional but quite serious abdominal injury seen in 0.3 % of all pediatric trauma patients [7]. This type of injury typically results from blunt force incidents, such as bicycle handlebar injuries, and motor vehicle crashes which compress the pancreas against the lumbar vertebrae [8].

Younger thinner children are more liable to this type of traumatic injury as they have less adipose tissue insulating their internal organs [2]. Our patient fit the classic profile since he was a slight five-year-old boy who sustained blunt pancreatic injuries following a bicycle handlebar incident a year ago.

Such traumatic events may cause pediatric acute pancreatitis (AP) [9]. Notably, 15–35 % of children with AP develop acute recurrent pancreatitis (ARP), which may in turn lead to chronic pancreatitis (CP) [9,10].

According to INSPPIRE, ARP is characterized by more than two instances of acute pancreatitis with recovery to normal in between [11]. CP is diagnosed when structural variation in the pancreas, including diffuse or localized damage, sclerosis, and abnormalities in the pancreatic duct, is associated with one of the following [12]:

• •Periods of constant abdominal pain or three times the normal upper limit of lipase or amylase values.
• •Exocrine pancreatic insufficiency.
• •Endocrine pancreatic insufficiency.

Children suffering from CP mainly experience persistent abdominal pain, accompanied by symptoms such as nausea, vomiting, anorexia, and weight loss [11]. Following the pancreatic trauma, our patient endured constant abdominal discomfort along with fatty diarrhea and weight loss indicating exocrine pancreatic dysfunction. This consensus helped establishing the diagnosis of post-traumatic CP.

Serum amylase and lipase levels are either normal or slightly elevated [11]. Elevated serum levels of transaminases, direct bilirubin, ALP, and GGT may occur in biliary obstruction [11]. Our patient had relatively elevated levels of amylase, lipase, GPT and GOT. Those findings are consistent with CP.

Imaging methods to diagnose CP are endoscopic ultrasound (EUS), magnetic resonance imaging (MRI), and abdominal ultrasound [13]. Trans-abdominal ultrasound is the initial investigation but has low accuracy in evaluating pancreatic anatomy [2]. MRI is the gold standard for children due to its reliability in detecting chronic changes [2].

Since MRI scans are relatively expensive and unavailable in all Syrian medical centers and hospitals, a multi-slice computed tomography (MSCT) scan was performed for the patient despite the high radiation exposure. Results were unremarkable, showing no abnormalities.

Ductal abnormalities and pancreatic atrophy are the characteristic radiographic signs. Although considered a standard sign of CP in adult population, pancreatic calcifications are uncommon findings in pediatric CP [14].

Pain control presents a significant challenge when managing chronic inflammation [10]. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first choice to reduce pain, in addition to opioids in severe or burdened pain [10]. ERCP intervention is necessary in cases of ductal identifiable structures and obstructions [11].

In our case, we gave the patient NSAIDs alongside opioid prescriptions for pain management.

Children diagnosed with pancreatitis are at greater risk for complications considering their underdeveloped organs and immature inflammatory response [15]. CP may have a devastating impact on the child's quality of life with frequent school absences, prolonged hospital stays, and limited physical activity [14]. Furthermore, exocrine pancreatic insufficiency associated with CP disrupts absorption of nutrients needed for growth, which leads to malnutrition and delayed development [16].

Disruption of the pancreatic duct remains an infrequent challenging complication of pediatric pancreatitis. Leakage of pancreatic secretions forms fluid collections around the pancreas known as pancreatic pseudocysts (PPCs), whereas fistulas to the pleural and peritoneal cavities result in pancreatic pleural effusion (PPF) and pancreatic ascites (PA) respectively [17,18].

Patients with PPF present with typical pleuropulmonary manifestations like pleuritic chest pain, dyspnea and shortness of breath [19], While PA usually manifests as progressive abdominal enlargement along with mild persistent tenderness [3].

Fluid analysis following aspiration is key to the diagnosis of pancreatic fistulas [18]. During both admissions, exudative fluids from our patient contained high levels of amylase, lipase and protein strongly indicating pancreatic involvement. Evaluation of the pancreatic duct via ERCP or MRCP can also confirm the diagnosis [20]. Since ERCP is an invasive modality, MRCP provides a safer and potentially more accurate alternative for pediatric patients [21]. Within the limits of our resources, the patient underwent ERCP to visualize the fistula pathway which appeared to be of a microscopic nature.

Other pathological mechanisms may play a role in the development of pleural effusion in patients with pancreatitis. Severe pancreatic inflammation can induce a sympathetic response in pulmonary capillaries, causing fluid leakage into the pleural space [22]. However, sympathetic effusions are usually small and self-limiting unlike the massive effusion seen in our case. Moreover, elevated amylase and lipase levels measured in the aspirated fluid further support the presence of a pancreatico-pleural fistula [22].

Treatment of pancreatic fistulas usually begins with 2 to 3 weeks of non-operative management comprising image-guided drainage of fluids, octreotide infusion therapy, in addition to fasting and intravenous nutrition [20]. Nevertheless, only 30 % to 60 % of all patients respond well when treated conservatively while others still require endoscopic or surgical interventions [18]. ERCP-guided stent placement alleviates pressure on the pancreatic duct and blocks fluid leakage through the fistula allowing for a definitive cure [23]. However, ERCP procedures are not always without consequences; complications like infection, hemorrhage, and perforation happen in 7 % to 25 % of cases and are potentially life-threatening [24].

We initially drained the patient's ascites and maintained appropriate pain management and dietary modifications. The patient was discharged upon clinical improvement only to relapse two months later indicating the need for other interventional measures. Eventually, we used ERCP to perform a pancreatic sphincterotomy followed by the insertion of a plastic stent. Somatostatin therapy was also administered to help reduce pancreatic secretions.

Approximately 25 % to 30 % of asymptomatic PPCs are at risk of developing complications like rupture, infection, intracystic hemorrhage, and obstruction of nearby anatomical structures [23]. In our case, the ERCP we performed to address the fistula resulted in the infection of the pseudocyst.

90 % of PPCs smaller than 4 cm in diameter disappear spontaneously with a conservative regimen of bowel rest, supportive nutrition, and analgesia [25]. Conversely, PPCs larger than 6 cm require operative management using one of several surgical techniques [26].

Despite having the lowest recurrence rate, surgical cyst-gastrostomy carries higher post-operative morbidity and mortality risks [17,26].

Meanwhile, indications for percutaneous drainage are firmly restricted due to delayed recovery, high risk of recurrence, and its association with cystic-cutaneous fistula formation [26,27]. However, it may still be performed in special cases such as with immature cysts or unstable patients [26].

Endoscopic drainage of pediatric PPCs remains an effective and less intrusive technique [26]. The procedure involves puncturing the cyst and then draining its contents into the gastric lumen through a plastic stent [27].

We initially favoured conservative management given the patient's fragile condition and the pseudocyst being asymptomatic at the time. Earlier intervention would have exposed the child and his family to unnecessary medical procedures and expenses.

As the pseudocyst became infected, we immediately started treatment with antibiotics. Then we followed the endoscopic approach using an ultrasound needle to aspirate pus from the cystic cavity. Finally, we placed two plastic stents to avoid recurrence and then removed them four weeks later.

4. Conclusion

In conclusion, timely diagnosis of pancreatic ductal injuries requires a high sense of clinical suspicion to spare pediatric patients the risks of rather infrequent but critical complications. ERCP is an excellent diagnostic and therapeutic tool but may occasionally cause serious consequences including infection. Optimal management remains unclear with an overall tendency towards the least invasive approach possible.

Author contribution

F.A.K, L.M, and L.A are joint first author, contributed to drafting, editing, reviewing, and bibliography.

H.K. contributed to reviewing, and training.

J.M. and F.S. contributed to Supervision.

All authors read and approved the final manuscript.

Consent

Written informed consent was obtained from the patient's parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Our institution does not require ethical approval for reporting individual cases or case series.

Guarantor

Farah Abou Kheir

Leen Moustafa

Loujain Ahmad

Research registration number

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Funding

Not applicable.

Conflict of interest statement

The authors declare that they have no competing interests.

Data availability

Not applicable.