Christina Awad, MD1, Ryan Cho, MD2, Charles Miller, MD1
1Brooke Army Medical Center, San Antonio, TX; 2San Antonio Uniformed Services Health Education Consortium, San Antonio, TX
Introduction: Blunt trauma injuries to the pancreas are rare but carry a significant mortality and high complication rate. Motor vehicle collisions are the leading cause for blunt pancreatic trauma in adults. Patients with pancreatic trauma typically present with features of acute pancreatitis, which is often difficult to diagnose due to other intra-abdominal injuries. The Organ Injury Scale is the most widely accepted grading system for pancreatic trauma. The higher the grade of injury, the more likely surgical intervention is required. Pancreatic duct (PD) disruption has traditionally required surgery if PD stenting during ERCP was not feasible. We report a case of delayed complete PD disruption following blunt trauma that was successfully treated endoscopically.
Case Description/Methods: A 58 year-old female with no prior history of pancreatitis presented with intermittent abdominal pain four months after a motor vehicle collision. CT showed a 6.7 x 8 cm pancreatic body cyst. ED evaluation at the time of the MVC had not included abdominal imaging and a CBC and CMP were normal. EUS revealed a 7.5 x 6.7 cm pancreatic body cyst without septation or mural nodule. FNA with a 19Ga needle fully collapsed the cyst. A pancreatic pseudocyst was confirmed with an amylase of 7500 U/L and CEA of 0.4 ng/mL. Patient reported alleviation of her pain following cyst aspiration, however MRCP 4 days after FNA revealed complete re-accumulation of cyst fluid (figure1). ERCP with pancreatogram confirmed complete PD disruption (figure2). Following surgical consultation, the patient opted for EUS-guided intervention for long-term cyst stenting. EUS with cystogastrostomy was successfully performed with a 15x10mm Axios lumen-apposing metal stent (LAMS) and 7Fr x 7cm double pigtail stent. At planned LAMS removal, the pigtail stent had migrated making repeat pigtail stenting challenging, but successful. Three month follow-up imaging showed the pigtail stent in the prior cyst cavity with plan to leave the stent indefinitely (Figure3).
Discussion: This is a rare case of PD disruption presenting 4 months after blunt trauma and without preceding pancreatitis. While PD disruption has traditionally required surgical intervention, endoscopic cystogastrostomy with long-term plastic stenting is a novel option to avoid surgery. Given difficulty placing the plastic pigtail at the time of LAMS removal and to avoid a second procedure, it is worth considering placement of plastic pigtail stents rather than a LAMS during the initial procedure.
Citation: Christina Awad, MD; Ryan Cho, MD; Charles Miller, MD. P1004 - DELAYED PRESENTATION OF A TRAUMATIC COMPLETE PANCREATIC DUCT DISRUPTION SUCCESSFULLY TREATED WITH ENDOSCOPIC CYSTOGASTROSTOMY AND LONG-TERM PLASTIC STENTING. Program No. P1004. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.