The patient was a pillion passenger in a road traffic accident involving posterior impact. He arrived at the emergency department conscious, fully oriented and maintaining his own airway, with a Glasgow Coma Scale of 15. His principal symptoms were abdominal pain and persistent tachycardia that did not resolve after intravenous crystalloid resuscitation. Although systolic blood pressure was maintained and he was otherwise hemodynamically stable, the continuing tachycardia prompted urgent cross-sectional imaging. Abdominal examination showed mild diffuse tenderness, most marked in the epigastrium, without guarding, rigidity, rebound tenderness or clinical signs of peritonitis. Bowel sounds were audible, and there was no seat-belt sign, flank bruising or external abdominal wall injury. Examination of the chest, pelvis and limbs was also unremarkable, with no clinical evidence of concomitant extra-abdominal injury.

Initial laboratory testing showed hemoglobin of 11.8 g/dL, a total leukocyte count of 9.6 × 10^3/μL and platelets of 138 × 10^3/μL. Serum amylase was elevated at 597 U/L, while total bilirubin was 2.25 mg/dL, alanine aminotransferase was 19 U/L and alkaline phosphatase was 86 U/L. The international normalized ratio was 1.32, while prothrombin and activated partial thromboplastin times were within acceptable limits; arterial blood gas analysis showed no acidosis. Renal function and electrolytes were within normal limits. The elevated amylase was compatible with pancreatic injury but could not establish or exclude main pancreatic duct disruption because its diagnostic sensitivity and specificity are limited in the early hours after blunt abdominal trauma. Persistent tachycardia despite fluid resuscitation was therefore the principal clinical signal that significant internal injury might be present despite the relatively benign abdominal examination.

Portal venous phase CT revealed hypodense linear defects in the pancreatic tail, focal parenchymal discontinuity, peripancreatic fat stranding and a localized fluid collection measuring approximately 4.8 × 3.7 cm, interpreted as hematoma. Mild haemoperitoneum was present, but no active contrast extravasation was identified. The liver, spleen, kidneys, bowel loops and major abdominal vessels appeared unremarkable. These findings supported a provisional AAST Grade III injury involving the pancreatic tail, with suspected disruption of the main pancreatic duct. Importantly, CT did not directly demonstrate the duct or prove that it had been transected. Its diagnostic contribution was indirect: focal disruption of pancreatic tissue combined with an adjacent collection suggested that the injury extended into the main duct. The distinction is important because ductal integrity is a major determinant of management in pancreatic trauma, and the sensitivity of CT for directly visualizing duct disruption can vary, particularly early after injury.

The diagnostic assessment also considered a Grade I or II pancreatic contusion or laceration without ductal involvement, which might have permitted nonoperative management. Other possibilities included injury to the liver, spleen or kidneys, hollow-viscus or mesenteric damage, and a retroperitoneal hematoma of vascular origin. The apparently normal appearances of the other abdominal organs, bowel loops and major vessels made several alternatives less likely, while the pancreatic findings supported the working diagnosis of isolated distal pancreatic injury with suspected ductal disruption. Dedicated assessment with magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography could have provided direct evidence of duct continuity. Neither was undertaken because the clinical circumstances did not permit those procedures without delaying operative exploration. The authors therefore characterize the CT interpretation as a well-founded suspicion rather than a confirmed diagnosis. Concordance between one CT examination and one laparotomy cannot establish the sensitivity or specificity of the imaging signs used.

At operation, the surgical team found approximately 30 mL of haemoperitoneum and fat saponification involving the omentum and bowel loops. Exploration confirmed complete transection of the pancreatic tail with disruption of the main pancreatic duct, corresponding to the category of injury suspected before surgery. The spleen was viable and uninjured, and the splenic artery and vein were intact. Initial consent and operative planning had allowed for distal pancreatectomy with or without splenectomy because treatment of distal pancreatic injury may require removal of the spleen when the splenic vessels are involved. Direct inspection instead permitted spleen-preserving distal pancreatectomy, avoiding the lifelong risk of overwhelming postsplenectomy infection and the associated need for vaccination and prophylaxis in an otherwise healthy adolescent. A closed-suction drain was placed in the pancreatic bed, intravenous antimicrobial prophylaxis was administered at induction, multimodal analgesia was provided, and pharmacological venous thromboembolism prophylaxis began on the first postoperative day.

Definitive surgery was performed under general anesthesia through an upper midline laparotomy on the day of admission, without an intervening period of nonoperative observation. Intraoperative blood loss was otherwise minimal, and no blood products were required. Somatostatin analogue therapy was not administered. Intravenous crystalloid was continued after surgery, oral intake was reintroduced early and tolerated, and the drain was removed on postoperative day 5, when the patient was discharged. His postoperative course was uneventful: drain output was minimal, pain was mild and controlled with standard analgesia, and there was no fever, surgical-site infection, respiratory compromise or sepsis. The report records no postoperative pancreatic fistula by International Study Group of Pancreatic Surgery criteria, intra-abdominal collection, pseudocyst, wound complication or readmission. At the two-week outpatient review, the wound was healing satisfactorily, the patient had no abdominal symptoms and his repeat serum amylase had normalized.

Follow-up extended through six months, with the patient attending scheduled appointments and remaining asymptomatic. He had resumed his studies and ordinary activities without limitation, and no clinical signs of endocrine or exocrine pancreatic insufficiency were observed. Surveillance consisted of symptom review, clinical examination and biochemical testing; no formal dynamic endocrine or exocrine function tests were performed, so subclinical insufficiency cannot be excluded. Six months is also a relatively short period for ruling out late pseudocysts or delayed pancreatic insufficiency, and longer surveillance remains necessary. The absence of complications was therefore an observed outcome in this case, not proof that immediate resection or preoperative CT suspicion prevented them. No causal inference is possible from a single case without comparison groups, and the management described was consistent with established guideline-based care rather than a new treatment strategy.

The report’s educational value lies in showing how indirect CT signs can support a consequential preoperative decision. Focal parenchymal discontinuity and peripancreatic fluid did not conclusively demonstrate a disrupted main pancreatic duct, but together they provided a credible basis for expecting a high-grade distal injury. That interpretation was considered alongside persistent tachycardia and the inability to obtain dedicated ductal imaging without delaying surgery, allowing operation to proceed directly to definitive assessment. The approach also carries a trade-off: relying on suspicion can lead to surgery for an injury that dedicated ductal imaging might show to be lower grade. In this patient, however, operative findings confirmed the anticipated ductal disruption, and spleen-preserving distal pancreatectomy was followed by discharge after five days and an uncomplicated six-month course. The case therefore illustrates a distinction that matters in trauma imaging: indirect abnormalities can inform surgical planning while remaining less than definitive. The operative findings retrospectively supported the preoperative suspicion, but one successful correlation cannot establish that CT alone predicts ductal transection or that the timing of surgery produced the observed recovery.

Subject of Research: Preoperative CT suspicion and operative confirmation of main pancreatic duct injury in isolated blunt pancreatic trauma

Article Title: Preoperative CT Suspicion of Main Pancreatic Duct Injury in Isolated Blunt Pancreatic Trauma: A Case Report With Operative Correlation

Article References: Kazmi, S. S., Qamar, S. Z., Ali, A., Fatani, M. S., Haider, S. A., Farhan, M., Raza, A. A., & Samadi, A. (2026). Preoperative CT Suspicion of Main Pancreatic Duct Injury in Isolated Blunt Pancreatic Trauma: A Case Report With Operative Correlation. Clinical Case Reports, 14(10), Article e73760. https://doi.org/10.1002/ccr3.73760

Image Credits: AI Generated

DOI: 10.1002/ccr3.73760

Keywords: pancreatic trauma, main pancreatic duct, computed tomography, blunt abdominal injury, duct transection, distal pancreatectomy, spleen preservation, case report, Preoperative, Suspicion, Main, Pancreatic