LAUSR

A 48-year-old male presented for surgical evaluation with the diagnosis of chronic pancreatitis (CP). His symptoms began with an episode of acute pancreatitis and splenic rupture 10 years ago following motor vehicle accident (MVA), which was conservatively managed. Subsequently, he experienced chronic abdominal pain with episodes of severe pain requiring 3–4 hospitalizations per year. During those years, he endorsed a history of alcohol and tobacco consumption, with gradual abstinence of alcohol use over the last 3 years. However, his symptoms continued to worsen and he became narcotic dependent. He was evaluated by a gastroenterologist. He was noted to have mild exocrine insufficiency requiring pancreatic enzymes and preserved endocrine function (HbA1c of 5.7, and C-peptide of 3.0). The patient was evaluated with magnetic resonance imaging (MRI)/MR cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS). Uniquely, MRI showed abnormality of only the distal 50% of the pancreatic body and tail. The head and neck were unremarkable. On T1 non-contrast images, the pancreatic body and tail looked less bright than the rest of pancreas (Fig. 1). On contrasted images, it showed abnormal enhancement in the arterial phase and retention in the delayed phase, suggestive of severe fibrosis in that part of gland (Fig. 2). The splenic vein was thrombosed with multiple collaterals in that region. The spleen was normal. EUS had a similar appearance of severe chronic pancreatitis changes isolated to the pancreatic tail region, and almost normal sonographic changes were noted in the pancreatic head/body region. He was taken to the operating room for distal pancreatectomy, possible total pancreatectomy with autologous islet cell transplant pending the observed extent of disease. Intra-operatively, he was indeed found to have gross preservation of the pancreatic head and neck with well-demarcated fibrotic changes distal to the portal vein (Fig. 3). He was thus able to undergo distal pancreatectomy and splenectomy and preserve his pancreatic head. He had an uneventful recovery and showed significant improvement in pain and quality of life at the 6-month follow-up visit. Traumatic pancreatic injury is a rare subset of obstructive pathologies that can lead to chronic pancreatitis secondary to post-traumatic pancreatic duct scars. It has been proposed that blunt trauma to the pancreas results in stenosis and fibrosis of the pancreatic duct at the site of injury, and ultimately leads to chronic inflammation of the segment of the pancreas that is unable to be adequately drained distal to the site of ductal injury. The portion of pancreas proximal to the point of obstruction drains normally; thus, this parenchyma will remain normal on pre-operative imaging and intra-operatively. In some series, this form of chronic postobstructive pancreatitis represented only up to 8% of all cases presenting for surgical management of chronic pancreatitis. Though there was history of alcohol consumption in our patient, this complete sparing of the head and neck of the pancreas proves trauma to be the etiology. * Chirag S. Desai [email protected]