Ultrasound

of Epigastric

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L. CHRISTOPHER

Injuries

FOLEY’

AND

Blunt trauma to the epigastrium may result In a retroperltoneal hematoma Involving the head of the pancreas and descending duodenum. Secondary effects Include obstruction of the gastrIc outlet, obstruction of the blllary tree, and extrinsic compression of the Inferior vena cava. Four patients with epigastric trauma were reviewed who had been examined by ultrasound of the abdomen. Ultrasound showed the extent of the retroperitoneal hematoma, Its effect on contiguous organs, and was helpful in clinical management.

The radiographic features of injuries following trauma to the epigastrium are well documented However,

ultrasonic

jury to the neum have sL’ffered

blunt

arid

ultrasonic

their

findings

associated

upper gastrointestinal not yet been described. trauma

to

the

Case

are

Case

blunt [1-4].

closed

are

in-

reported

discussed.

Reports

1

T. M.

Medical vomiting.

,

a 12-year-old

boy,

was admitted

to Children’s

Center after 24 hr of epigastric Physical examination disclosed

Hospital

pain, nausea, a moderately

and dis-

tressed boy whose abdomen was silent to auscultation. On palpation, there was marked tenderness and guarding with spasm in the right upper quadrant and epigastrium. No mass was palpable. The only abnormal laboratory findings were a white blood cell count of 14,000/mm3 and an amylase of 247 caraway U/dl (normal, less than 150 UIdI).

Initial diagnostic examination onstrated a 4 x 6 cm echogenic anterior

to the

right

kidney,

of abdominal ultrasound demmass just right of the midline, and

posterior

to the

liver.

It ex-

tended inferiorly, parallel to the spine and psoas muscle (fig. 1A). The vena cava was compressed by the mass. The gallbladder was mildly dilated, but there was no dilatation of the common duct nor of the intrahepatic ducts. Diagnosis of a retroperitoneal hematoma extending along the tissue planes of the anterior pararenal space and involving the pancreas and duodenum

was

made

after

the

patient

recalled

a blow

to

(fig.

of the duodenum (fig. 1B). The patient slowly conservative management. Resolution of the mass over several months was documented by examinations. No sequelae were recognized

1C).

July

Department Address reprint 1

AJR 132:593-598, © 1979 American

25, 1978;

accepted

after

of Radiology, Children’s requests to A. L. Teele. April 1979 Roentgen

revision

December

Hospital

Medical

with

fluid.

Diagnosis

was

retroperitoneal

hematoma

in the

anterior pararenal space involving the duodenum and pancreas with obstruction of the stomach and first part of the duodenum.

27, 1978. Center and Harvard

593 Ray Society

2

G. B., a 15-year-old boy, was well until he developed abdominal pain and pernicious vomiting 24 hr before admission. A blow to the epigastrium during a soccer match 3 days before admission was followed by development of a small bruise. Because of this trauma and the finding of a serum amylase level of 2,780 caraway U/dl, initial evaluation was abdominal ultrasound, which disclosed a mass anterior to the right kidney and posterior to the liver, but separate from these structures (fig. 3A). It extended along the psoas muscle to the level of the pelvis compressing the inferior vena cava. The gallbladder appeared normal. The gastric antrum and duodenal bulb were distended

Comment. In this patient, ultrasound findings prompted questions about the possibility of abdominal trauma and led to the diagnosis of a retroperitoneal hematoma with traumatic pancreatitis. Although not proven, the combination of appropriate trauma, radiographic findings, and clinical resolution supported this suspicion.

Received

TEELE’

Case 3

the

epigastrium with a hockey stick 7 days earlier. Upper gastrointestinal series showed the typical radiographic features of an intramural and extramural mass involving the second portion improved with retroperitoneal serial ultrasound

LITTLEW000

K. B., a 12-year-old boy, was well until he had abdominal pain and dizziness, followed by nausea and vomiting, 24 hr before admission to Children’s Hospital Medical Center. Physical examination disclosed diffuse abdominal tenderness, maximal in the right lower quadrant, with rebound tenderness. His temperature was 38#{176}C. White blood cell count was 22,700/mm3 and hematocrit was 40. Tentative diagnosis was appendicitis, but at operation the appendix was normal. However, a large retroperitoneal hematoma surrounded the descending duodenum, extending inferiorly in the root of the mesentery to the level of the cecum. The retroperitoneum was not opened. No blood or fluid was found within the peritoneal cavity. When his history was reviewed, the patient recalled that 2 days before admission he had fallen onto the handle bars of his bicycle. Upper gastrointestinal series the day after surgery showed complete obstruction of the gastric outlet. Abdominal ultrasound demonstrated a well defined mass of the hematoma in the epigastrium between the liver and right kidney. It extended from the inferomedial edge of the liver across the midline to the aorta, and inferiorly to the level of the iliac crest paralleling the right psoas muscle and the kidney (fig. 2A). It encompassed both the descending duodenum and the head of the pancreas. The common bile duct and gallbladder were dilated; a fluidl sludge level in the gallbladder from biliary stasis was present. The gastric antrum and duodenal bulb were dilated and filled with fluid (figs. 2B and 2C). The patient gradually improved on conservative management with intravenous hydration and nasogastric suction. His serum amylase, 200 caraway UIdI in the immediate postoperative state, slowly decreased to normal. Serial examinations with ultrasound showed resolution of the hematoma. Comment. The traumatic pancreatitis, retroperitoneal hematoma, and probable duodenal hematoma in this child are fairly typical of an injury to the epigastrium following a direct fall onto the handle bars of a bicycle. Ultrasound accurately confirmed the su rgically discovered retroperitoneal hematoma . Secondary mild obstruction to the biliary tree was also documented.

and retroperitoFour patients who

epigastrium

examinations Case

with

tract

RITA

After Blunt Trauma

Medical

School,

300 Longwood

Avenue,

Boston.

Massachusetts

02115.

0361 -8o3x/79/1324-o593

$0.00

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594

ULTRASOUND

OF

EPIGASTRIC

AJA:132,

INJURIES

April 1979

Fig. 1.-Case 1. A, Transverse scan shows ovoid cross section of suspected retroperitoneal hematoma. m = mass, L = liver, k = kidney, P = psoas, S = spine, A = aorta. B, Extrinsic and intramural components of retroperitoneal hematoma involving descending duodenum. C, At 3 months, transverse scan shows resolution of mass.

The patient slowly improved with conservative management. Upper gastrointestinal series 2 weeks after admission showed delayed gastric emptying and extrinsic compression, as well as submucosal “thumbprinting” of the second portion of the duodenum consistent with duodenal involvement by the retroperitoneal mass (fig. 3B). Serial ultrasound examinations showed slow resolution of the retroperitoneal mass and no evidence of development of a pancreatic pseudocyst. Comment. Abdominal ultrasound delineated the location of the retroperitoneal injury in this patient, information not available by clinical or plain radiographic examination. Further, the dilatation of the gastric antrum and duodenal bulb, coupled with the patient’s clinical picture, documented obstruction in the second portion of the duodenum. Case

4

M. P., a 14-year-old girl, fell from a pony and suffered a concussion that made details of the accident vague. She developed left upper quadrant and left flank pain 6 months after the accident. Radiographic studies disclosed a “pancreatic abnormality” and medical management began. However, symptoms persisted, and the patient was referred to Children’s Hospital Medical Center where, 18 months after injury, physical examination was normal. The only laboratory abnormality was a serum amylase of 220 caraway UIdl. Supine abdominal radiography showed several 2 mm to 1 cm calcific densities in the pancreas. Hypotonic duodenography demonstrated anterior

displacement of the stomach and anterior, inferior displacement of the ligament of Treitz (fig 4A). Abdominal ultrasound showed enlargement of the body and tail of the pancreas with multiple echogenic foci representing calcification within the pancreas (figs. 4C and 4D). A pseudocyst was not identified. A small amount of ascitic fluid was present around the liver. Endoscopic retrograde cannulation of the pancreatic duct revealed a normal proximal duct with a ‘ ‘pseudocyst’ ‘ about 2 cm from the ampulla of Vater. There was a short stricture just distal

to this collection;

the

rest of the

pancreatic

duct

was

dilated and contained several calcific stones (fig. 4B). At laparotomy, a markedly enlarged, inflamed, edematous pancreas was found. The pancreatic duct was quite dilated and contained numerous calcific concretions. A small pseudodiverticulum from the pancreatic duct was identified. A Peaustow pancreaticojejunostomy with Aoux-en-Y anastomosis was constructed to drain the distal pancreas. Subsequently, the patient did well. Comment. We assume that this child’s fall resulted in a laceration of the pancreatic duct and the subsequent formation of the small pseudocyst and the stricture that caused distal obstruction. Discussion Blunt pediatric sequellae ted to

abdominal

trauma

is a common

problem

of the

patient. Fortunately, significant intraabdominal are rare [6-8]. In one series of children admitthe hospital for abdominal trauma, about 3%

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AJR:132,

April

FOLEY

1979

AND

595

TEELE

Fig. 2.-Case 2. A, Longitudinal scan shows surgically proven retroperitoneal hematoma (m) with compression of inferior vena cava (V). Duodenum (D) dilated with nasogastric tube (arrowhead) in lumen. L = liver, P = portal v,p. B, Transverse scan through porta hepatis shows portal v#{231}in (P), hepatic artery (H), and dilated common bile duct (B). V = vena cava. C, Dilated gallbladder (G) contains fluid/sludge level. Duodenum (D) is dilated.

sustained isolated pancreatic lated duodenal injuries [4].

Injury trium applied Because

to the usually

retroperitoneal occurs

and

structures

after

to a small area the pancreas

over and

focal

the total soft organs

damage

a situation

force to the

with

inevitable complain radiation, days after

bound veals

Vital

reveals tenderness. a slightly

signs

are

upper

usually

abdominal Laboratory

elevated

white

there has been a large amount of retroperitoneal bleeding, a low hematocrit. If the pancreas has been injured, elevated levels of amylase and lipase are apt to be present in the serum and urine. It should be emphasized that the history of trauma may not be elicited early in the clinical course and only be recalled by the patient much later (cases 1, 2, and 4) [12-15]. With a knowledge of normal anatomy and its ultrasonic appearance [16-24], pathologic variation can be recog-

iso-

epigasa

force

of such a blow. The spine and ribs makes

almost

nation

had

and duodenum. are fixed in posi-

Clinically, these patients usually abdominal pain, with or without vomiting several hours to several episode.

8%

in the

trauma

the pancreas duodenum

tion, they absorb relation of these in such

injuries

normal.

Physical

and,

cell

nized.

re-

typically count

reand,

In

echogenic tion anterior

exami-

occasionally,

examination blood

[8-11]. of epigastric nausea, and the traumatic

if

three

of

our

patients,

mass was the predominant to the right kidney and

a well

circumscribed

finding. posterior

Its posito the liver

and its extension to, and even across, the midline indicated its location in the anterior pararenal compartment, thus involving the head of the pancreas and duodenal loop. In our one surgically proven case (case 3), the

596

ULTRASOUND

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-

-

--..

.

OF EPIGASTRIC

-

.

Fig. 3.-Case

3. A, Suspected

retroperitoneal hematoma (m) compresses inferior vena cava (V). B, Intrinsic compression of lateral portion of descending duodenum and large obstructing intramural mass.

mass demonstrated by ultrasound was shown to be a large duodenal and retroperitoneal hematoma. Similar surgical findings in patients with duodenal and retroperitoneal hematomas following trauma have been documented [2, 8, 11, 12]. The three patients with retroperitoneal injury had both extramural and intramural involvement of the duodenum. Conceivably, isolated mural hematoma of the duodenum could occur, and appear on ultrasonic scans as a smaller, more circumscribed mass. Dilatation of the first portion of the duodenum, an intraperitoneal structure that usually escapes direct involvement by the hematoma, is evident on ultrasound. Some estimate of the degree of duodenal obstruction can be made on the basis of the size of a dilated duodenal bulb. Gastroduodenal examination with contrast material is necessary if duodenal perforation is suspected [4]. The biliary tree can be effected primarily or secondarily. Obstruction of the common duct by hematoma, edema, or pancreatitis can occur (case 2) [4, 25]. This obstruction leads to biliary stasis with dilatation of the common bile duct, gallbladder, and hepatic radicles. A fluid/sludge level in the gallbladder formed by layering

INJURIES

AJA:132,

April

1979

of particulate matter in the static bile may be present. However, a fluid/sludge level in the gallbladder without dilated hepatic ducts is not a reliable sign of obstruction, since it may result from prolonged fasting or severe hepatic disease. Laceration of the common duct, a potential result of trauma to the epigastrium, cannot be diagnosed with ultrasound alone. Perhaps the presence of large amounts of intraperitoneal fluid would suggest this complication. Injuries to the pancreas after trauma fall into three categories: (1) simple contusion with edema, (2) hematoma or hemorrhage, and (3) varying degrees of laceration [11]. Usually, the best view for showing the tail of the pancreas is prone. The head and body of the pancreas are seen best on the supine scans. The distortion of the vascular landmarks and visualization of an assodated mass will permit diagnosis of pancreatic involvement [16, 19, 21]. In case 4, the small pseudocyst shown on endoscopic retrograde cannulation of the pancreatic duct was not seen because antral gas obscured the pancreas on supine scans. Decompression of the stomach by nasogastric suction or filling the antrum and duodenal bulb with water will allow ultrasonic visualization of abnormalities of the head of the pancreas. In addition, it has been shown that careful sector scanning of the pancreas will reveal dilatation (greater than 5 mm) of the pancreatic duct [25]. Most important are serial scans after the acute episode to search for pancreatic pseudocyst [27]. The inferior vena cava can be affected (cases 1-3), and it is best evaluated by longitudinal scans along its long axis. The potential exists for obstruction by anterior compression from the mass in the anterior pararenal space. In our patients, neither acute nor chronic sequelae resulted from compression of the inferior vena cava. When examining the epigastrium, the liver, spleen, and kidneys should also be examined to detect traumatic alterations. In addition, there should be a search for peritoneal fluid (case 4). Trauma to the epigastrium may result in a retroperitoneal hematoma in the anterior pararenal space. This hematoma typically involves the head of the pancreas and descending duodenum, with secondary effects on the biliary tree, inferior vena cava, and stomach. Ultrasonic examination can delineate the extent of the hematoma and can evaluate the organs affected by it. Ultrasound is also helpful in evaluating the delayed complications of abdominal trauma. Since

submitting

this

paper,

we

have

seen

two

more

patients with retroperitoneal hematoma after trauma. In one surgically proven case, the injury was complicated by a 1 .5 cm pancreatic pseudocyst with pancreatic duct dilatation shown by ultrasound. Serial examinations documented resolution of the pseudocyst, the ductal abnormality, and the retroperitoneal mass. The second case was almost identical to the first three cases reported here. The patient had a large retroperitoneal mass that resolved after several months.

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I T9 V ., ‘

4 ‘I,

EFT

4

598

ULTRASOUND

theduodenum 9. 10.

Freeark

110:695-703,

1965

WJ, Strohl EL: Intramural hematoma of the duodenum. Arch Surg 92:463-475, 1966 Andersson A, Bergdahl L: Intramural hematoma of the duodenum in children: review of literature and report of two cases.AmSurg 39:402-405, 1973

1 1 . Kinnaird

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in children.AmJSurg

abdominal 12. Aesnicoff

AJ, Corley

OF

EPIGASTRIC

19.

intramural duodenal hematomas. J Trauma 9:561-576, 1969 13. Mahour GH, Woolley MM, Gans SL, Payn VC Jr: Duodenal hematoma in infancy and childhood. J Pediatr Surg 6:153160, 1971 14. Donovan AJ, Turrill F, Berne CJ: Injuries of the pancreas from blunt trauma: Surg Clin North Am 52: 649-665, 1972 15. Judd DR. Taybi J, King H: Intramural hematoma of the small bowel. Arch Surg 89:527-535, 1964

20.

with gray scale ultrasound. Meyers MA: Radiological

Radiology

124:197-202,

1977

features of the spread and localization of extraperitoneal gas and their relationship to its source. Radiology 111:17-26, 1974 18. Gosink BB, Leopold GA: Ultrasound and the gallbladder. Semin Roentgeno! 11:185-189, 1976

April 1979

GA:

the

Filly

Gray scale ultrasonic angiography of Radiology 1 17 : 665-671 , 1975 RA, Carlsen EN: Newer ultrasonographic anatomy

the

upper

and

abdomen.

arteries with JCU4:91-96,

21

22.

.

23. 24.

Carlsen

26.

EN,

upper

note

Filly

AA:

abdomen.

major

systemic

on localization

veins

in

of the pancreas.

Echographic diagnosis of panscanning techniques and diag-

96:575-582, 1970 Newer ultrasonographic

I. The

anatomy. JCU 4 : 85-90, 1975 Goss CM (ed): Gray’s Anatomy, & Febiger, 1976 Meyers MA: Dynamic Radiology

Springer, 25.

a special 1975

II. The

Filly RA, Freimanis AK: creatic lesions: ultrasound nostic findings. Radiology the

16. Sample WF: Techniques for improved delineation of normal anatomy of the upper abdomen and high retroperitoneum 17.

Leopold

AJA:132,

upper abdomen.

AD, Norcross

DW: Pancreatic injuries due to nonpenetrating trauma. Am J Surg 91 : 552-557, 1956 SA, Morton JH: Changing concepts concerning

INJURIES

portal

and

anatomy

hepatic

29th ed. Philadelphia, of the Abdomen.

in

venous Lea

New York,

1976

Gosink BB, Leopold GA: The dilated pancreatic duct: ultrasound evaluation. Presented at the annual meeting of the American Institute of Ultrasound in Medicine, November 1977 Duncan JG, lmrie CW, Blumgart LH: Ultrasound in the management of acute pancreatitis. BrJ Radiol 49:858-862,

1977 27. Gonzalez AC, Bradley EL, Clements JL Jr: formation in acute pancreatitis: ultrasonographic tion of 99 cases. AJR 127:315-317, 1976

Pseudocyst evalua-