Surgical Science, 2011, 2, 459-462
doi:10.4236/ss.2011.29101 Published Online November 2011 (http://www.SciRP.org/journal/ss)
Post-Traumatic Necrohemorragic Pancreatitis
Caused by an Air Gun
Rocío González López*, Marlen Alvite Canosa, Eva Iglesias Porto, Mohammed Salem Ali,
Carlos Gegúndez Gómez, J. Félix Arija Val
Department of General Surgery of Hospital Lucus Augusti, Lugo, Spain
Received July 4, 2011; revised September 18, 2011; accepted Oc tob er 13, 2011
Abstract
Penetrating abdominal trauma is the main cause of pancreatic lesions and delay in diagnosis or treatment can
increase morbimortality. We present a case of acute necrohemorrhagic pancreatitis (ANHP) secondary to
airgun injury associated with pulmonary embolism caused by the projectile in a 36 year old man. He under-
went urgent surgery, appreciating pancreatic contusion but not visualizing the projectile, located by CT scan
3 mm from the inferior vena cava. The patient underwent further surgery 48 hours later for necrosectomy
and the insertion of an irrigation tube, due to ANHP after the migration of the projectile into the lung. This
case underlines the clinical relevance of pancreatic lesion in patients with a penetrating abdominal trauma,
the diagnostic difficulty and the surgical strategy, as well as the repercussions of the migration of a foreign
body through the blood stream, crossing the right heart chambers and becoming lodged in the lung.
Keywords: Penetrating Abdominal Trauma, Necrohemorragic Pancreatitis, Air Gun
1. Introduction
The incidence of pancreatic lesions in abdomin al traumas
is low, 0.2% to 6%, penetrating abdominal traumas, main-
ly due to sharp weapons or fire arms, being the most fre-
quent cause [1].
Isolated lesions of the pancreas are rare, due to its ana-
tomical proximity to other structures. The hepatic lesion
being the visceral lesion most commonly associated with
pancreatic lesions, 19.3%, followed by the stomach, 16%,
the spleen, 11%, and the colon 7.9%. Vascular lesions
occupy third place among lesions accompanying pancre-
atic trauma: 5.5% v enous (Inferior vena cava, po rtal vein
and superior mesenteric vein) and 4.5% arterial (aorta
and superior mesenteric) [1-3].
The distribution of the injuries varies in function of the
mechanism of the lesion. Penetrating lesions are distrib-
uted throughout the en tire pancreatic gland, while lesions
caused by closed trauma are usually located in the neck
of the gland [1] .
We present a case of acute necrohemorrhagic pan-
creatitis (ANHP) secondary to penetrating abdominal
trauma by airgun associated with pulmonary embolism
caused by the projectile.
2. Clinical Case
A 36-year-old man who came into the Emergency room
of our Hospital after suffering an abdominal trauma by
air gun projectile in the left hypochondrium.
During the physical examination the patient scored 15
on the Glasgow scale, was haemodynamically stable and
there was a visible entry wound in the left hypochon-
drium, with pain in the abdomin al region on palpation in
that area but with no guarding and the presence of intes-
tinal noises.
Additional tests show moderate leukocytosis with left
shift. A thoracic, abdominal, and pelvic CT scan with
oral and intravenous contrast was requested. This re-
vealed a projectile lodged in the retroperitoneum, 3 mm
from the inferior vena cava, with hyperdense areas and
blurring of the peripancreatic fat possibly related to a
slight lesion of the pancreatic gland, with no free fluid or
pneumoperitoneum (Figure 1).
An urgent exploratory laparotomy was carried out re-
vealing a paraduodenal haematoma with little free hae-
matological fluid. Min imal laceration of the hepatic edge
was appreciated with no evidence of bleeding, as well as
minimal laceration of the anterior gastric wall which was

460 R. G. LÓPEZ ET AL.
sutured with vicryl 3/0. The projectile was not identified
and paraduodenal aspiration drainage was left in place.
During the post-operative period the patient was ad-
mitted to the Intensive Care Unit (ICU). 48 hours after
the surgical intervention he presented significant clinical
worsening with intense abdominal pain, fever, tachycar-
dia and high leukocytosis with neutrophilia, for which
reason a new thoracic and abdominal TC scan was car-
ried out, showing a large amount of free intra-abdominal
fluid, mainly right pararenal and peripancreatic and de-
structuring of the pancreatic head, possibly related to
post-traumatic pancreatitis as well as objectifying the
projectile lodged in the left inferior pulmonary lobe
(Figure 2). Given these findings and the suspicion of
severe acute post-traumatic pancreatitis, it was decided
to carry out a new urgent surg ical intervention, finding a
large amount of serosanguineous fluid and acute necro-
hemorrhagic pancreatitis, mainly affecting the pancreatic
head. No point of vascular bleeding was observed in the
periduodenal region. Irrigation, debridement and pancre-
atic necrosectomy were carried out, leaving intra-ab-
dominal irrigation tubes in place.
The patient remained in the ICU for a long period of
time, with prolonged mechanical ventilation, respiratory
superinfection with E. coli and adult respiratory distress.
He was transferred to the ward 24 days after the surgical
intervention. The patient’s subsequent evolution was sa-
tisfactory with broad-spectrum antibiotic therapy and an
important radiological improvement in intra-abdominal
collections. He was discharged 75 days after the surgical
intervention. After 10 months of follow-up the patient is
asymptomatic and with the projectile still lodged in the
left inferior pulmonary lobe.
3. Discussion
The diagnosis of a pancreatic lesion after an abdominal
trauma requires a high level of suspicion, as any delay in
the diagnosis or in the treatment of this type of lesion can
cause a significant increase in morbimortality [1,3].
The diagnostic and treatment algorithm depends on the
clinical situation of the patient which can vary from
haemodynamic stability, as in our case, to a state of
shock, as well as on the means which each hospital has at
its disposal [4].
Helical CT scan with oral and intravenous contrast is
the test of choice for haemodynamically stable patients
who have suffered an abdominal trauma, as it makes it
possible to establish the diagnosis and gradation of pos-
sible intraperitoneal and retroperitoneal lesions. Mag-
netic resonance cholangiopancreatography (MRCP) may
diagnose those cases of doubtful lesions in CT acquisi-
tion [4-8].
Figure 1. Abdominal CT scan revealed a projectile lodged
in the retroperitoneum, 3 mm from the inferior vena cava,
with hyperdense areas and blurring of the peripancreatic
fat possibly related to a slight lesion of the pancreatic gland.
Figure 2. thoracic and abdominal TC scan showing a large
amount of free intra-abdominal fluid, mainly right parare-
nal and peripancreatic and destructuring of the pancreatic
head, related to post-traumatic pancreatitis as well as ob-
jectifying the projectile lodged in the left inferior pulmo-
nary lobe.

R. G. LÓPEZ ET AL.
461
Various procedures have been recommended for the
treatment of pancreatic trauma with different results.
Among the surgical options are: external drainage, de-
bridement, resection, reconstruction procedures and pan-
creatoduodenectomy, in function of the degree of the
lesion encountered, bearing in mind the current trend
towards a more conservative attitude [6 ]. In our case, we
initially encountered a pancreatic lesion grade 1 on the
American Association for the Surgery of Trauma scale,
for which reason irrigation and drainage were carried out
while, during the second intervention, the findings of
acute necrohemorrhagic pancreatitis made it necessary to
use debridement and drainage techni qu es .
The late appearance of peripancreatic, perihepatic or
subphrenic collections is frequent in pancreatic trauma
but the development of abscesses is very rare and is gen-
erally due to visceral lesions. Even more infrequent and
more severe is the appearance of pancreatitis with in-
fected necrosis, the treatment of which is very similar to
that for those of non-traumatic origin, percutaneous
drainage or surgery [6-8].
The embolization of the projectile to the left inferior
pulmonary lobe is an extremely rare entity, there being
no clearly established protocol for its treatment because
of the low incidence. When the projectile migrates th-
rough the vascular system, crossing the right heart cham-
bers, it may cause symptoms of: heart failure, taponade,
arrhythmia, pericarditis or embolic phenomena or, as in
our case, the patient may remain clinically and haemo-
dynamically asymptomatic [9].
The presence of foreign bodies within the pulmonary
parenchyma is very rare and its treatment is the subject
of discussion. If the patient presents clinical manifesta-
tions it is clearly a case for surgery but the discussion
becomes more widespread when the patient is asympto-
matic. The risk of developing abscesses, bronchiectasis
or recurring infections endorses the surgical recommen-
dation. There is also the risk of lesions with the poten tial
risk of haemorrhages, arteriovenous fistulas, etc. [10].
The success of a conservative treatment, as in the case
of our patient, is based on the fact that the projectile
lodged in the lung can be well tolerated and only requires
observation, as long as the patient remains asymptomatic.
Surgical exploration and removal must be considered
when there are clinical manifestations and always bear-
ing in mind the benefits and risks [10].
4. Conclusions
This case underlines the clinical relevance of pancreatic
lesion in patients with a penetrating abdominal trauma.
The diagnosis of a pancreatic lesion after an abdominal
trauma requires a high level of suspicion, as any delay in
the diagnosis or in the treatment of this type of lesion can
cause a significant increase in morbimortality. The sur-
gical strategy depends on the clinical situation of the
patient which can vary from haemodynamic stability, as
in our case, to a state of shock, as well as on the means
which each hospital has at its disposal.
The embolization of the projectile to the left inferior
pulmonary lobe is an extremely rare entity, there being
no clearly established protocol for its treatment because
of the low incidence. The success of a conservative
treatment, as in the case of our patient, is based on the
fact that the projectile lodged in the lung can be well
tolerated and only requires observation, as long as the
patient remains asymptomatic. The repercussions of the
migration of a foreign body through the blood stream,
crossing the right heart chambers and becoming lodged
in the lung, is unknown, its treatment is the subject of
discussion in many articles.
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