*Department of Radio-Diagnosis, SGT Medical College, Budhera, Gurgaon 122505, India.
Background: Pancreatic pseudocyst formation following blunt abdominal trauma is a lesser known entity in the pediatric age group as compared to pancreatitis. The pickup rate of various post-traumatic hidden pathologies is now possible because of modern diagnostic armamentarium.
Case Presentation: We present a 3-year-old girl who reported with blunt abdominal trauma and developed pancreatitis. She subsequently developed pseudocyst in the follow-up period of management. Modern diagnostic tools like ultrasonography, computed tomography, and magnetic resonance imaging helped in clinching the diagnosis.
Conclusion: Blunt abdominal trauma in children should be taken seriously from the diagnostic as well as management point of view. We can manage the case as per the complications with the help of various diagnostic modalities, as was done in our present case.
Keywords: Pseudocyst, pancreatitis, ultrasonography, computed tomography, MRI, case report.
Pancreatitis is a known entity following blunt abdominal trauma in adults, but the incidence is less common in children. Pseudocyst formation is one of the sequelae which arise following blunt abdominal trauma. The over-all incidence of pseudocyst formation is 1.6%–4.5% and 0%–69% are post-traumatic. Pseudocyst is surrounded by fibrous capsule which is not lined by the endothelium.
A 3-year-old female child reported with pain in the abdomen with off and on vomiting for two days’ duration. She was of average built ( Figure 1).
There was past history of blunt trauma 6 weeks back for which she was treated conservatively for traumatic pancreatitis. She was discharged with the subsequent fortnightly follow-up. On examination, her vitals were stable. Blood pressure was 120/60 mm of Hg and pulse 76 beats per minute. The abdomen was soft but there was a small swelling in the epigastric region, which was slightly tender. The rest of the systemic examination was unremarkable. Plain x-ray of the thoraco-abdominal region was done, which did not show any abnormality ( Figure 2).
Serum amylase and lipase were slightly raised. Ultrasound examination revealed a cystic mass measuring 5.14 × 4.9 × 4.0 cm at the junction of the pancreatic head and body. There was some debris noticed within the lumen and it was not communicating with any other organ ( Figure 3a,b).
Contrast enhanced computerized tomography (CECT) of the abdomen was done, which revealed the cystic mass (8 HU) near the body region with a very thin marginal wall. This was adjacent to the pancreas, which appeared to be of normal density ( Figure 5a,b,c).
Magnetic resonance imaging (MRI) studies were done to see the relation to the liver and the pancreatic tubular structures. The lesion was hypointense on T1W and hyperintense on T2W ( Figure 6a,b,c).
MRI balanced turbo-field-echo sequences revealed the exact extent of the pseudocyst with the surrounding architectural structures ( Figure 7a,b).
Magnetic resonance cholangio-pancreaticography (MRCP) did not reveal any communication with either common bile duct or pancreatic duct ( Figure 8).
Pseudocyst is a known complication following pancreatitis, but is slightly less common in the pediatric age group. The most common cause for this entity is following trauma in children. There is compression injury to the pancreas as it lies anterior to the spine. The most frequent pancreatic injury is in the head and body regions, because of their anatomical placement [ 2]. Ultrasonography is the initial modality of choice to diagnose any collection or cystic mass of the organ. CFI further adds to the diagnosis to differentiate it from the vascular pathologies. MRI helps in anatomic details and further delineation of the cystic mass. MRCP is an invaluable tool in finding any communication with the biliary or pancreatic tree. Conservative treatment is always preferred in children. This includes bowel rest and total parenteral nutrition. The cutoff line for management is the size of the cyst. If the size is more than 5 cm, surgical maneuver is indicated, otherwise it is treated conservatively [ 3]. These cysts can become complicated by rupture, hemorrhage, or infection. Percutaneous drainage can be done safely, but recurrence is common. This is indicated in infected and non-septated pseudocysts. There was a complete resolution of pseudocysts in the series of 9 cases by Sharma and Maharshi [ 5] and all had endoscopic drainage [ 4, 5].
The management of pediatric pseudocyst depends on the size of the cyst and the associated extent of injury. The management can be contemplated by percutaneous, endoscopic procedure or internal drainage, depending on the guidelines described. Percutaneous drainage has always shown poorer outcome than surgical cases.
We are thankful to Mr. Nitish Virmani, Ms Nitika, Rajdeep, and Raushan of the Faculty of Allied Health Sciences of SGT University, Gurgaon, for carrying out the radiological investigations and for procuring the images.
Contrast enhanced computerized tomography
Color flow imaging
Magnetic resonance cholangio-pancreaticography
Magnetic resonance imaging
Informed consent of parents was taken to report this case.
1, 2, 2, 2, 2
- Department of Pediatrics, SGT Medical College, Budhera, Gurgaon, India.
- Department of Radio-Diagnosis, SGT Medical College, Budhera, Gurgaon, India.
- Benifla M, Weizman Z. Acute pancreatitis in childhood: analysis of literature data. J Clin Gastroenterol 2003; 37(2):169–72. https://doi:10.1097/00004836-200308000-00015
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- Shilyansky J, Sena LM, Kreller M, Chait P, Babyn PS, Filler RM, et al. Nonoperative management of pancreatic injuries in children. J Pediatr Surg 1998; 33(2):343–9. https://doi:10.1016/S0022-3468(98)90459-6
- Teh SH, Pham TH, Lee A, Stavlo PL, Hanna AM, Moir C. Pancreatic pseudocyst in children: the impact of management strategies on outcome. J Pediatr Surg 2006; 41(11):1889–93. https://doi:10.1016/j.jpedsurg.2006.06.017
- Sharma SS, Maharshi S. Endoscopic management of pancreatic pseudocyst in children: a long-term follow-up. J Pediatr Surg 2008; 43(9):1636–9. https://doi:10.1016/j.jpedsurg.2008.01.026
|Patient (gender, age)||1||3-year-old female child|
|Final Diagnosis||2||Post-traumatic pancreatic pseudocyst|
|Symptoms||3||Pain in abdomen following blunt trauma|
|Clinical Procedure||5||Underwent US, CECT, and MRI studies|