Interesting Case

One of the reasons I went into Emergency Medicine is that on every shift, there is the potential for an interesting case. I suspect there are many people in Emergency Medicine and Emergency Medical Services who are of the same opinion. We all tolerate the mundane cases, the repetition of influenza cases in January and the long nights with no patients. You do all of this knowing there that there is still part of this job that gets your attention when you see something that you didn't expect, or haven't seen very often.

Look at the image above as I give you the details of this case.

This is a young person who came in saying he fell on the steps in the past few days and has vomiting and abdominal pain. Part of the reason he fell was that he was drinking, but he and his partner assure me that he had not overdone it and that his symptoms were not from a hangover.
He has normal vitals, but was very uncomfortable. I did a bedside ultrasound and saw no free fluid i.e blood, so I started into by speech about pain and muscle contusions and how unlikely it is that there is anything wrong internally.
Blunt trauma to the abdomen can cause damage to wither the spleen or liver, most commonly. The term used is spleen laceration or liver laceration, but they are more like fractures or bruises. With blunt trauma, that is the injury you worry about, unless the mechanism is atypical, like a handlebar to the abdomen or if someone throws a shoe at you. But "Who throws a shoe? Honestly."

When you have a focal impact to your abdomen, you can bruise your bowel which will cause pain. Then, once the bowel swells, you will stop passing food and you start to vomit. That process can take up to 48 hours and that did not fit really well in the case I am presenting here.

I kept looking at the patient and decided he was in to much pain to send home without formal imaging, hence the CT scan image you see above. What is outlined in green is the patient's pancreas and it is broken in half. This is rare, painful and has the potential for many long term complications. The treatment is placing a stent in the pancreatic duct using upper endoscopy. You do this because you don't want the pancreatic enzymes that normally digest food leaking into your abdomen and wreaking havoc on your abdominal organs.

An unusual case that is worth bringing up because it is easy to let your guard down when you hear a mechanism that so often leads to no significant injury. I even make jokes about how I see people who fall on the stairs everyday, yet I still brave the steps in my house.

Extra credit: Send me note and tell me what is represented by the dark area I have identified with an orange circle.

Paul