Pancreatic rupture during childbirth treated successfully by endoscopic drainage

A 22-year-old woman was referred to our hospital for intensifying epigastric pain, 3 days after giving birth. The last stage of labor had been assisted by manual compression of the uterus, during which the patient had a painful, tearing sensation in the upper abdomen. Initial laboratory findings were as follows: hemoglobin 91 g/L, white blood cell count 21500 /µL, and amylase 567 IU/L. Abdominal computed tomography (CT) revealed near-total rupture of the pancreas ([Fig. 1]).

Fig. 1 Near-total rupture of the pancreas (large arrow) and free fluid in the abdominal cavity (small arrows) in a young woman a few days after giving birth.

The patient underwent endoscopic retrograde cholangiopancreaticography, and a leak from the main duct of pancreas was noted ([Fig. 2]). The distal portion of the pancreatic duct and the rupture site were dilated using a 4 mm/4 cm balloon, followed by placement of a 12 cm/5Fr stent ([Fig. 3]). Subsequently, an ultrasound-guided drain was inserted into the upper abdomen. The patient was kept on parenteral nutrition and somatostatin therapy for 7 days. Due to presence of pleural effusion a drain was introduced into the left pleural cavity. The patient developed paralytic ileus, which was treated conservatively. At 2 days following stent placement, a follow-up abdominal CT revealed no complications ([Fig. 4]). The patient was discharged 12 days after admission. No complications were evident on abdominal magnetic resonance imaging at 2 months and the stent was removed after 3 months. At 6 months, secretin-stimulated magnetic resonance cholangiopancreaticography revealed no pathology ([Fig. 5]) and the patient had fully recovered.

Fig. 2 The guide wire in the distal portion of the pancreas. The contrast medium had leaked from the main duct (large arrow) to the peripancreatic space (small arrows).

Fig. 3  The stent was successfully introduced over the rupture site (large arrow). Another stent is seen lying in the stomach after a failed attempt (small arrow).

Fig. 4 Follow-up computed tomography (CT) image 2 days after the placement of the stent.

Fig. 5 Magnetic resonance cholangiopancreaticography showing no ductal abnormalities or fluid collections.

The most important factor determining the outcome of pancreatic injuries is ductal integrity [1] [2]. Distal lacerations with ductal involvement, grade III according to the pancreas Organ Injury Scale [3], are traditionally treated with resection [4]. In the present patient, the diagnosis was made after 3 days. Delay is associated with increased morbidity and complication rate. However, external drainage, pancreatic stenting, and otherwise conservative treatment led to complete recovery in the present case.

Endoscopy_UCTN_Code_CCL_1AZ_2AM

Competing interests: None

• References

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