Case Report
A 9-year-old boy was admitted to our hospital with abdominal pain after falling from his bike. His medical history revealed that he fell from his bike facedown 15 minutes before admission. His Glasgow Coma Scale (GCS) was normal at 15. Abdominal examination revealed tenderness on all abdominal quadrants by palpation. Initial vital signs were normal; however, focused assessment with sonography for trauma (FAST) showed common free fluid in the abdomen mainly on perihepatic, Morrison’s pouch. His general condition was stable, so abdominal computed tomography (CT) was ordered. The CT scan showed a grade IV liver laceration on the falciform ligament enhancing left portal vein 6 cm in diameter, leading to free fluid (Figures 1, 2, and 3). Laboratory test results revealed that his blood group was O Rh(−) and other parameters were Hb: 10.6 g/dl, Hct: 31.1%, AST: 397 U/L, ALT: 280 U/L. Urgent pediatric surgery consultation was requested. His vital signs declined, and hypotension and tachycardia ensued. One unit of O Rh(−) erythrocyte suspension was administered. He became confused and vital signs were as follows: Blood Pressure 60/40 mm/Hg and pulse rate was 136/minute. Perioperative haemoglobin was Hb: 2.75 g/dl and Hct was 13%. On laparatomy one liter of free blood was suctioned by surgeon. Examination revealed total laceration of extrahepatic bile ducts and right lobe, as well as 60% laceration of left lobe. Portal vein sustained a 70% laceration. The portal vein was clamped first, and then repaired by cardiovascular surgeon. Then lacerated liver segments and extrahepatic bile ducts were repaired. Abdomen was closed following placement of a drain. A total of 12 liters of blood were transfused. He was discharged after full recovery.
Figure 1 Grade 4 laceration and free fluid.
Figure 2 Common free fluid.
Figure 3 Portal vein laceration.
Discussion
The portal vein forms as the superior and inferior mesenteric veins join with the splenic vein behind the pancreas. The average portal vein diameter is 2 cm, and this vein has a blood pressure of 10 mm Hg. The injury to the portal vein can be devastating because of the high flow rate, which averages one litre per minute.Reference Dawson, Johansen and Jurkovich 6 Grade I or II injuries are generally considered minor and usually do not require operative treatment, whereas grades III to V injuries are severe and often require operative management. Significant vascular (portal vein or hepatic artery) injuries can be associated with a hematoma or parenchymal laceration (grade III) but usually ocur with major parenchymal disruption (grades IV and V).Reference Badger, Barclay and Campbell 7 In their 1995 multi-institutional review of injuries to the portal triad, Jurkovich et al. reported 46 patients with penetrating injuries to the portal triad, including injuries to the portal vein. They reported a 38% survival rate when only the portal vein was injured and an 8% survival rate when other structures in the portal triad were injured. This included a 100% mortality rate for six patients with portal vein and hepatic artery injury. All three of the patients with injuries to the portal vein, extrahepatic bile duct, and hepatic artery died.Reference Jurkovich, Hoyt and Moore 5 Traumatic portal vein injuries are rare and devastating. For 18,900 trauma patients evaluated during a 10-year period, 15 (0.08%) were identified as having injury to the portal vein. Pearl et al. reported on a case of a 22-year-old male with injuries to the portal vein, hepatic artery, common bile duct, hepatic vein, and pancreas from a gunshot wound. The portal triad injuries, in this case, were managed by primary repair of both the portal vein and hepatic artery with ligation of the right hepatic duct.Reference Pearl, Chao and Kennedy 8
Herein, we report the case of traumatic injury of portal vein and extrahepatic bile ducts besides liver laceration in a pediatric patient after a relatively minor trauma and initially presenting with stable vital signs and abdominal pain. As a rare and highly mortal traumatic complication, portal vein injury must be diagnosed and treated urgently; however, the initial presentation in a child may be misleading. It is prudent to consider this injury with abdominal pain after blunt trauma, even when it is considered relatively minor, and pursue appropriate monitoring and evaluaton to facilitate urgent intervention, particularly in children.
