Traumatic pancreatic injury during playing sports

Abstract

The patient was a 33-year-old man. He had severe upper abdominal pain after a rugby game and he was diagnosed with traumatic pancreatic injury. Since intra-abdominal bleeding became severe, laparotomy was performed for haemostasis. On operation, venous bleeding from the upper edge of the head of the pancreas was found and the haemorrhage was stopped. The whole pancreas had severe inflammation with oedematous tissue spreading into the meso-colon and meso-jejunum. On the same day, the patient was transferred to our hospital for further treatment of acute pancreatitis. On admission, the amylase level in the drainage fluid was high and, thus, we started continuous arterial infusion treatment via the superior mesenteric artery, in addition to subcutaneous administration of octreotide. Enteral nutrition was started on postoperative day 6, oral intake was started on postoperative day 15. The patient recovered successfully and was discharged on postoperative day 30.

BACKGROUND

Pancreatic injury is caused by direct external invasion, and pathological conditions caused by the injury can be severe and fatal especially in cases of traumatic pancreatitis. Pancreatic injury is a comparatively rare traumatic injury accounting for 1–2% of abdominal injuries.¹ Most cases develop as blunt pancreatic injury caused by a handle of an automobile in a traffic accident or by a bicycle handle in children.² The number of cases of pancreatic injury in sports is small, with only 11 such cases found in PubMed and MEDLINE searches, and there is no information on the treatment and prognosis of the disease. Here, we report a case in which a pancreatic injury occurred in rugby training, and we review the characteristics, treatment and prognosis of pancreatic injury in sports activities.

CASE PRESENTATION

The patient was a 33-year-old man with a chief complaint of severe upper abdominal pain. He had received an injury when he was tackled during a rugby game in October 2008. After the game, he had severe upper abdominal pain and was taken by ambulance as an emergency to a previous hospital. He was diagnosed with traumatic pancreatic injury.

TREATMENT

CT findings at the hospital (fig 1a) showed damage to the anterior surface of the head of the pancreas and intra-abdominal bleeding. Endoscopic retrograde pancreatography (ERP) at the showed leakage of contrast material from the main pancreatic duct in the head of the pancreas. An injury to the main pancreatic duct was diagnosed and an endoscopic retrograde pancreatic drainage (ERPD) tube was placed (fig 1b).

Figure 1.

(a) CT at admission to previous hospital indicating damage to the head of the pancreas (indicated by a white arrow) and free space on the surface of the liver (indicated by a dotted arrow). (b) ERP image showing leakage of contrast agent in the main pancreatic duct in the head of the pancreas (indicated by a white arrow).

Since intra-abdominal bleeding became severe, laparotomy was performed for haemostasis. On operation, venous bleeding from the upper edge of the head of the pancreas was found and the haemorrhage was stopped. The whole pancreas had severe inflammation with oedematous tissue spreading into the meso-colon and meso-jejunum; thus, drainage tubes were placed in the upper and lower side of the pancreas, bilateral subphrenic area and in the foramen of Winslow. Cholecystectomy was added.

On the same day, the patient was transferred to our hospital for further treatment of acute pancreatitis. Acute pancreatitis score was 8 using Japanese severity score.³ On admission, the amylase level in drainage fluid was high (15 000 IU/ml) and, thus, we started continuous arterial infusion treatment via the superior mesenteric artery (SMA). Nafamostat mesilate (240 mg/24 h) and imipenem (3 g/day) were administered for 1 week. Systemic administration of methanesulfonate (FOY) (600 mg/day) was also performed, in addition to subcutaneous administration of octreotide (200 μg/day). Sivelestat (elaspol) was administered at a dose of 4.8 mg/kg/day for 14 days for acute respiratory failure associated with severe pancreatitis.

OUTCOME AND FOLLOW-UP

On postoperative day 3, the patient was moved to a general ward. Enteral nutrition was started on postoperative day 6, but was discontinued due to fever and an increase of the serum amylase level. These symptoms were improved by antibiotic and pancreatic enzyme inhibitor treatment and, thus, oral intake was started on postoperative day 15. The patient recovered successfully and was discharged on postoperative day 30 (fig 2). He plays rugby again after 2 months’ discharge.

Figure 2.

Clinical course transferred to our hospital.

DISCUSSION

Including this case, 12 cases of pancreatic injury caused during playing sports have been reported in the literature (table 1).^1,4–11 These include 10 male and 2 female patients, suggesting that the injury is observed more in males. The average age was 22.6 years old. The sports included Australian Rules football (AFL) (3 cases), football,³ rugby,² karate,¹ skiing,¹ snowboarding,¹ and mountain biking.¹ The injury in 9 cases was caused by contact between players and that in the remaining 3 cases was caused by sports gear.

Table 1.

Cases of pancreatic injury caused during playing sports reported in the literature

Case	Sports	Age	Gender	Cause of injury	Time to diagnosis (less than 6 h: yes)	Location	Classification	Peek of serum amylase (IU/L)	CT	ERP	MRCP	Main treatment	Operation	Hospital stay (days)	Prognosis	Author	Publish
1	Soccer	16	M	Contact	Yes	Tail	IIIa	N/A	No	No	No	Conservative	DP +splenectomy (6 h after injury)	14	Alive	Harrison et al4	1985
2	Karate	40	M	Contact	Yes	Head	IIIa	2429	Yes	Yes	No	Ope	DP (15 weeks after injury)	115	Alive	Nielsen et al8	1986
3	Ski	40	M	Ski board crash	No	Body	II	1090	Yes	No	No	Conservative	No	11	Alive	Noguti et al9	1992
4	Soccer	16	M	Contact	No	Head	II	1248	Yes	No	No	Ope	Drainage and jejunostomy	25	Alive	Rawls et al15	2001
5	Rugby	18	M	Contact	No	Head	II	3481	Yes	No	No	TAE	No	33	Alive	Nakagawa et al6	2003
6	Soccer	17	M	Contact	No	Body	IIIa	491	Yes	Yes	Yes	Conservative	No	49	Alive	Ushida et al14	2004
7	Snow board	32	F	Pole crash	No	Body-tail	II	1078	Yes	No	No	Ope	Laparoscopic and drainage (12 h after injury)	13	Alive	Narita et al7	2006
8	Bicycle	13	F	Handle	No	Tail	II	2847	Yes	No	No	Conservative	No	48	Alive	Kaneko et al5	2007
9	AFL	16	M	Contact	No	Tail	I	378	Yes	No	No	Conservative	No	6	Alive	Burton et al2	2007
10	AFL	15	M	Contact	Yes	Tail	II	269	Yes	No	No	Conservative	No	6	Alive	Burton et al2	2007
11	AFL	15	M	Contact	Yes	Tail	II	778	Yes	No	No	Ope	Cyst-gastrostomy (5 months after injury)	N/A	Alive	Burton P et al2	2007
12	Rugby	33	M	Contact	Yes	Body	IIIb	430	Yes	Yes	No	Ope	Drainage and jejuno stomy (3 days after injury)	30	Alive	Present case	2009

AFL, Australian rules football; DP, distal pancreatectomy; ERP, endoscopic retrograde pancreatography; F, female; M, male; MRCP, magnetic resonance cholangio pancreatography; ope, operation; TAE, transcatheter aorterial embolisation.

Regarding the time from development of the injury to diagnosis, five cases took 6 hours or less (1–4 h) and seven cases took 6 hours or more (9–48 h), including two that required 2 days or longer. For diagnosis of pancreatic injury, CT was effective in 11 of the 12 cases. ERP was performed in three cases in which injury of pancreatic duct was suspected and pancreatic duct drainage was performed in two cases with partial laceration. Serum amylase levels were high in all cases with a median level of 1078 IU/L (269–3481 IU/L).

The injury sites included the tail (5 cases), head (three cases), body (two cases) and body-tail (one case). Grades of I, II and III were reported in one, seven and four patients (IIIa: 3; IIIb: 1), respectively, based on the classification proposed by the Japanese Association for Surgery of Trauma (table 2). Regarding treatment, the single grade I patient and three of the seven grade II patients improved with conservative treatment. The other four grade II patients received surgical treatment, including two who required drainage: one received selective embolisation (TAE) and one received cyst-gastrostomy for a pseudo-cyst. Three of the grade III patients underwent ceriotomy or laparoscopic surgery, including two treated with pancreatectomy (distal pancreatectomy and splenectomy, and distal pancreatectomy, respectively) and one with drainage. The other grade III patient improved following endoscopic nasopancreatic drainage (ENPD).

Table 2.

Classification of pancreatic injury in Japan

Grade	Observation
I	Contusion
II	Laceration
IIIa	Ductal injury: distal
IIIb	Ductal injury: proximal

I: The pancreatic capsule is maintained with no intraabdominal leakage of pancreatic fluid;

II: Not accompanied by injury of the main pancreatic duct;

III: IIIa: Injury of the main pancreatic duct in the body of the pancreas and caudal portion; IIIb: Accompanying injury of the main or sub-pancreatic duct in the head of the pancreas.

The average hospitalisation period of the 12 patients was 31.8 days, with average periods of 39.4 days for the 6 patients who received surgical treatment and 27.5 days for the 6 patients who were treated conservatively. The hospitalisation period did not differ significantly between the types of treatment. All 12 patients recovered without any problems.

Traumatic pancreatic injury is a comparatively rare disease, but has a reported mortality of as high as 16–43%.^12–15 Pancreatic injury alone occurs in only a few cases and is more often associated with damage to the spleen, liver or duodenum. The injury is caused when the pancreas is wedged by the spine due to high external pressure on the abdominal region resulting in haemorrhage and leakage of pancreatic fluid. Such leakage may then cause acute pancreatitis with induction of inflammation of surrounding organs and development into a fatal condition.²

As described above, pancreatic injury in sports activities has been reported in only 12 cases, most of which involved young men and had damage to the pancreas only unlike other cases of pancreatic injury. Development of symptoms occurred at a late stage in many of the cases and few were diagnosed in the early phase with more than half diagnosed more than 6 hours after injury. None of the cases were fatal, but careful observation is still required in cases of possible pancreatic injury. CT is effective for diagnosis of pancreatic injury caused by sports activities and 11 of the 12 cases in the literature were diagnosed based on CT. However, it is difficult to diagnose pancreatic ductal injury by CT only and, thus, MRCP and ERP are also performed. MRCP was used in one case, but the injury site could not be determined clearly, whereas ERP was performed in three of the four grade III patients to determine the sites of pancreatic ductal injury.

Various treatment methods are used for pancreatic injury. Patients with lower grade injury may improve during follow-up, but two reported grade II patients developed a complication of a pseudo-cyst during observation. Cyst-gastro drainage was performed for one patient on day 14 according to US guidelines,⁸ and cyst-gastro drainage was performed by laparotomy for another patient at 5 months after development of the injury.¹¹ Therefore, follow-up observation is required even for patients with low-grade injury, based on possible development of a pseudo-cyst. For grade III patients, aggressive treatment is required. Pancreatic duct drainage can be performed for partial injury, while pancreatectomy is used for complete laceration. Improvement of endoscopic techniques in recent years has also led to active use of endoscopic treatment. Three of the four reported grade III patients underwent ERP, with two with partial injury showing favourable results after ENPD and ERPD.⁷ It is likely that endoscopic treatment will be the first-line approach for future cases with partial injury. In addition, endoscopic observation in abdominal surgery can be performed to select haemostasis or drainage treatment in cases with suspected intra-abdominal bleeding and leakage of pancreatic fluid in CT.

A pancreatic enzyme inhibitor (nafamostat mesilate, FOY) was used as conservative treatment in 4 of the 12 patients. All four patients were Japanese and this drug was used as the first-line treatment for acute pancreatitis. Intervention radiology was performed for two patients: one of grade II received TAE and the other of Grade IIIb received arterial infusion treatment. Both patients developed the injury while playing rugby. Continuous arterial infusion (CAI) therapy was one of the treatment options for sever acute pancreatitis. In our case, we performed CAI therapy, because amylase level in drainage fluid was high we suspected still uncontrolled pancreatic juice leakage. Takeda et al revealed that CAI therapy was effective for reducing mortality and preventing pancreatic infection and acute pancreatitis.¹⁶ Imaizumi et al compared CAI therapy with non-CAI treatment in patients with severe acute pancreatitis.

They suggested that CAI may decrease the need for surgical treatment and the cumulative survival rate in the CAI group was significantly higher than that in the non-CAI group.¹⁷ From our case, CAI is the one of the treatment option in patients who had acute pancreatitis caused by sports-related pancreatic injury. Interventional radiology is thought to be effective for patients with partial haemorrhage or a complication of severe acute pancreatitis.

LEARNING POINTS

• This injury typically occurs as a single injury in young men, unlike in other cases of pancreatic injury.

• The time from occurrence of the injury to diagnosis was relatively long in many cases, and careful follow-up is necessary for patients with abdominal contusion, although none of the reported cases were fatal.

• CT was effective for diagnosis in the acute phase and in follow-up.

• Endoscopic nasopancreatic drainage and endoscopic retrograde pancreatic drainage are necessary for patients with partial laceration of the pancreatic duct, whereas patients with complete laceration require pancreatectomy for survival.