lNTRODUCTlON

Because of the deep anatomical location of the pancreas, traumatic pancreatic rupture is relatively rare. The pancreas lies adjacent to the stomach, liver, duodenum, small intestine, colon, and other important organs, as well as large blood vessels in the abdominal cavity; therefore, pancreatic injury is typically associated with damage to other organs and blood vessels, with isolated harm to the pancreas accounting for only 14% of all pancreatic injuries[1]. Isolated pancreatic injury most often occurs during severe upper abdominal trauma. There have been no reports of isolated pancreatic injury caused by abdominal massage. In this report, we describe a very rare case of pancreatic injury following abdominal massage, which caused massive abdominal hemorrhage.

CASE PRESENTATlON

Chief complaints

A 57-year-old woman had acute abdominal pain for 1 d, which worsened in the last 12 h.

The portraits of the old citizens became alive, steppeddown from the walls against which they had hung for centuries, andtook seats near the church door

History of present illness

The patient had developed persistent severe upper abdominal pain 1 d previously, which could be relieved by rest. The upper abdominal pain worsened in the last 12 h, accompanied by nausea, vomiting, and transient syncope, prior to her presentation at the emergency center of a tertiary hospital.

History of past illness

She had hypertension and denied a history of surgery and/or trauma.

In conversation following the operation, the patient told us that she had undergone abdominal massage the day before the abdominal pain occurred. At the time, she felt the massage had been very powerful and painful. On detailed questioning, she had no other injuries. Because the pancreas is a retroperitoneal organ and is protected by the abdominal wall, stomach, and colon, injury is not likely. Pancreatic injury occurs in only 0.2% of patients who endure blunt abdominal injury[9]. Closed pancreatic injuries are most often traffic injuries. The soft pancreas can be squeezed by external forces, such as a steering wheel or bicycle handlebars, and collides with the hard spine behind, causing local pancreatic injury or even rupture. It is not difficult to imagine that any high-intensity external force acting on the abdomen may cause varying degrees of pancreatic damage. Although there is no direct evidence, we consider that abdominal massage caused the pancreatic injury in our patient, based on her medical history. Recent studies have shown[10,11] that abdominal massage can reduce gastric residual volume and the incidence of abdominal distension by mechanically stimulating intestinal movement, as well as increasing the frequency of defecation, with no obvious adverse effects detected. In a previous report, an elderly man was admitted to the hospital with sudden abdominal pain; he had received a vigorous massage the day before its onset and was found to have isolated mesenteric injury during surgery, which had caused severe abdominal hemorrhage[12]. Similar to the pancreas, isolated mesenteric injury after blunt abdominal trauma is also very rare, as external force needs to be directly transmitted to the mesentery to cause it to tear. The medical history of our patient was very similar to this previous report, providing strong evidence that vigorous abdominal massage can be a cause for pancreatic injury. Therefore, deep and powerful abdominal massage should be avoided.

Personal and family history

After the operation, the patient was transferred to the intensive care unit for treatment. After sedatives were discontinued on the first postoperative day, she gradually became conscious and could complete simple commands. However, her hemodynamics remained unstable, volume expansion was required, and norepinephrine administered

a syringe pump. She gradually recovered after comprehensive treatment, including somatostatin, ulinastatin, antibiotics, blood transfusion, and nutritional support. The patient developed a pancreatic fistula 15 d after the operation, and the abdominal pain was significantly reduced after continuous negative pressure drainage through the spiral negative pressure drainage tube. The drainage fluid gradually reduced from 100 to 20 mL per 24 h by the 21

d after surgery. The abdominal drainage tube placed in the right abdomen was then removed. The patient recovered well after the operation and was discharged on the 24

d after surgery. The patient attended our clinic for reexamination one month after the operation. The abdominal drainage tube on the left abdomen had no drainage in the past 4 d, and the blood-related examinations and amylase were normal. We considered the patient’s pancreatic fistula to be cured, and the abdominal drainage tube was hence pulled out.

Then the Queen was shocked, and turned yellow and green with envy. From that hour, whenever she looked at Snow-white, her heart heaved in her breast, she hated the girl so much.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Physical examination

When she arrived at the hospital, she was conscious but unwell and her face was pale. Her body temperature was 35.5 ℃, blood pressure was 13.2/10.2 kPa, heart rate was 105 beats/min, breathing rate was 26 beats/min, and blood oxygen saturation was 99%. There was no ecchymosis in the abdomen, obvious tenderness in the umbilical area and upper abdomen, and no rebound pain or muscle tension. Abdominal percussion was dull, and no bowel sounds were heard.

Laboratory examinations

Faced with unexplained abdominal bleeding, it is sometimes difficult to make accurate judgments, and emergency laparotomy can be used to determine the cause and save lives. Exploration of the abdominal cavity revealed old bloody fluid, with hematoma in the lesser omental sac, and paraduodenal hematoma beyond the retroperitoneum, all of which suggested pancreatic injury. Intraoperative exploration confirmed that the pancreas was damaged and bleeding. According to the American Association for Traumatic Surgery pancreatic injury grading standard (Table 1), the patient was confirmed to have grade III injury[4]. According to relevant research instructions, grade I and II injuries should be treated conservatively when the hemodynamics are stable and there are no other abdominal cavity injuries that urgently require surgery; whereas, grade III, IV, and V injuries usually require surgical treatment, with distal pancreatectomy being the first choice for grade III pancreatic injury[5]. As far as possible, distal pancreatectomy aims to ligate the pancreatic duct alone. Stapler suture alone after distal pancreatectomy is a fast and safe suture method, which is not inferior to other suture techniques, and does not increase the possibility of pancreatic fistula or other abdominal complications[6]. For patients with stable hemodynamics, the spleen should be preserved, which can effectively reduce the risk of dangerous infection complications and thromboembolism after surgery[7,8]. Although the patient’s condition was complex and critical, and the slow emergence of the clinical signs of pancreatic injury delayed diagnosis and treatment, fortunately, timely surgical treatment controlled the dangerous abdominal bleeding and saved her life.

Imaging examinations

Written informed consent was obtained from the patient for publication of this case report and accompanying images and clinical data.

FlNAL DlAGNOSlS

The patient was diagnosed with massive abdominal hemorrhage secondary to pancreatic rupture.

TREATMENT

In the emergency center, we quickly established intravenous access and infused 4U O-type red blood cells, 400 mL plasma, and 4U cryoprecipitated clotting factor. Blood pressure was 12.5/9.7 kPa, heart rate was 106 beats/min, and hemoglobin was retested as 63 g/L after transfusion. To determine the cause of the bleeding, we performed exploratory laparotomy. Surgery revealed extensive old hemorrhage in the abdominal cavity, hematoma in the omental sac, retroperitoneal hematoma, injury to the pancreatic body, and hemorrhage from blood vessels on the back of the pancreatic body. After suturing and hemostasis, exploration showed that approximately three quarters of the transverse diameter of the pancreas was damaged, and there were hematomas behind the pancreas, colon, and mesentery root. As the pancreatic injury was too large to be repaired, a pancreatic body and tail resection was performed. The pancreas was transected from the ruptured area, and the proximal end was sutured to arrest the bleeding. We used a disposable endoscopic wire-cutting stapler with a length of a 2.5-mm nail to remove the vessels near the tail of the pancreas and part of the splenic hilum. The lateral width of the distal pancreas tissue was about 4 cm. As the vital signs of the patient were stable during the operation, we retained the spleen. The wound stopped bleeding and two abdominal drainage tubes were properly placed. The operation was completed uneventfully.

OUTCOME AND FOLLOW-UP

The personal and family history of patients are unremarkable.

DlSCUSSlON

Preoperative analysis

When the patient was admitted to the hospital, she denied any history of trauma or surgery, and no evidence of trauma was detected on physical examination. CT could objectively reveal abdominal cavity damage, and the time required for examination is relatively short. Hence, this technique has an important role in routine diagnosis and treatment of acute abdominal pain[2]. Therefore, we chose to conduct a CT examination, which clearly showed the intra-abdominal hemorrhage. There was a largescale exudation in the pancreatic area, accompanied by a variety of high-density and low-density shadows, considering the possibility of hematoma. There were also multiple cystic lesions in the liver. Because the patient was anemic, we first considered intra-abdominal hemorrhage of unknown etiology or pancreatic disease to exclude abdominal trauma. Sudden severe abdominal pain accompanied by hemorrhagic shock is similar to the symptoms of abdominal aortic aneurysm rupture, and combined with the patient’s history of hypertension, this possibility could not be ruled out[3].

The cards I bought, Topps, still included a piece of gum, unlike many of the newer brands. The smell of the gum, the cardboard, the ink, and the wax paper brought the baseball memories of my youth rushing back as surely as did that first whiff of mown grass in the spring. I flipped2 through the cards, recognized a few of the players names, and then put them away.

Surgical exploration

Preoperative blood test showed that white blood cell count was 11.76 × 10

/L, neutrophil percentage was 85.8%, hemoglobin was 77.00 g/L, and the D-dimer quantification was 1.54 mg/L.

Finding the cause

At the word of the Fairy the rocks and stones rose and built themselves into a beautiful castle, and before sunset it was all furnished inside, and left nothing to be desired

CONCLUSlON

To our knowledge, this is the first case report of a pancreatic rupture caused by abdominal massage. Appropriate abdominal massage is beneficial to relieve abdominal distension and constipation; however, vigorous abdominal massage should be avoided, as it can cause life-threatening damage to the internal organs and tissues of the abdomen.

FOOTNOTES

Sun SL collected patient information, reviewed the literature, and drafted the manuscript; Tuo HF performed the operation, and reviewed and revised the manuscript before submission; Zhang LL and Yu WM revised documents and manuscripts; and all authors contributed to the article and approved the submitted version.

Abdominal computed tomography (CT) showed no abnormalities in the soft tissue and bone structure of the abdominal wall. There was a large amount of fluid in the abdominal cavity, and some of it had a slightly higher density. Multiple round-like density shadows with clear borders could be seen in the liver parenchyma, and the larger ones were about 39 mm in diameter; the intrahepatic bile ducts were not dilated. The pancreas was not clearly displayed, large-scale exudation could be seen in and around the pancreas (Figure 1A), the surrounding fat gap was blurred, and multiple clusters of high- and slightly low-density shadows could be seen around the pancreas, the larger of which was about 8.8 cm × 6.4 cm in size (Figures 1B and 1C). The adjacent peritoneum and bilateral prerenal fascia showed thickening. Pelvic CT showed a small amount of effusion in the pelvic cavity, and there was no obvious abnormality in the uterus and appendages. Chest CT showed mild emphysema in both lungs, and no pleural effusion was seen on either side.

I had several choices on Saturday. Clean the garage, wash the car or go to the golf store and waste hours looking at a bunch of stuff I couldn’t afford.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/Licenses/by-nc/4.0/

China

As soon as they came before the king he said to them, You brothers have said that you could, if you liked, get for me a lamp that can shine over seven kingdoms

Bing-Lun Sun 0000-0002-8859-4135; Liang-Liang Zhang 0000-0002-8729-5483; Wei-Ming Yu 0000-0001-7738-7280; Hong-Fang Tuo 0000-0001-9226-2830.

Wang JJ

A

Okay, he said, helping10 me down the stairs and to the curb11, I m going to stay here and keep an ear out for the babies. I ll tell you when it s safe to cross. You go over to the coke machine, get your coke and come back out. Wait for me to tell you when it s safe to cross back.

Wang JJ

1 Biffl WL, Moore EE, Croce M, Davis JW, Coimbra R, Karmy-Jones R, McⅠntyre RC Jr, Moore FA, Sperry J, Malhotra A, Feliciano D. Western Trauma Association critical decisions in trauma: management of pancreatic injuries.

2013; 75: 941-946 [PMⅠD: 24256664 DOⅠ: 10.1097/TA.0b013e3182a96572]

2 Heiken JP, Katz DS, Menu Y. Emergency Radiology of the Abdomen and Pelvis: Ⅰmaging of the Non-traumatic and Traumatic Acute Abdomen. 2018 Mar 21. Ⅰn: Diseases of the Abdomen and Pelvis 2018-2021: Diagnostic Ⅰmaging - ⅠDKD Book [Ⅰnternet]. Cham (CH): Springer; 2018- [PMⅠD: 31314362]

3 Barrionuevo P, Malas MB, Nejim B, Haddad A, Morrow A, Ponce O, Hasan B, Seisa M, Chaer R, Murad MH. A systematic review and meta-analysis of the management of visceral artery aneurysms.

2020; 72: 40S-45S [PMⅠD: 32553135 DOⅠ: 10.1016/j.jvs.2020.05.018]

4 Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG. Organ injury scaling, ⅠⅠ: Pancreas, duodenum, small bowel, colon, and rectum.

1990; 30: 1427-1429 [PMⅠD: 2231822]

5 Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, Robinson BR, Nagy K, Armen SB, Kingsley S, Gupta S, Starr FL, Moore HR 3rd, Oliphant UJ, Haut ER, Como JJ. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma.

2017; 82: 185-199 [PMⅠD: 27787438 DOⅠ: 10.1097/TA.0000000000001300]

6 Peck GL, Blitzer DN, Bulauitan CS, Huntress LA, Truche P, Feliciano DV, Dente CJ. Outcomes after Distal Pancreatectomy for Trauma in the Modern Era.

2016; 82: 526-532 [PMⅠD: 27305885]

7 Nikfarjam M, Rosen M, Ponsky T. Early management of traumatic pancreatic transection by spleen-preserving laparoscopic distal pancreatectomy.

2009; 44: 455-458 [PMⅠD: 19231557 DOⅠ: 10.1016/j.jpedsurg.2008.09.026]

8 Pommerening MJ, Rahbar E, Minei K, Holcomb JB, Wade CE, Schreiber MA, Cohen MJ, Underwood SJ, Nelson M, Cotton BA. Splenectomy is associated with hypercoagulable thrombelastography values and increased risk of thromboembolism.

2015; 158: 618-626 [PMⅠD: 26209572 DOⅠ: 10.1016/j.surg.2015.06.014]

9 Iacono C, Zicari M, Conci S, Valdegamberi A, De Angelis M, Pedrazzani C, Ruzzenente A, Guglielmi A. Management of pancreatic trauma: A pancreatic surgeon's point of view.

2016; 16: 302-308 [PMⅠD: 26764528 DOⅠ: 10.1016/j.pan.2015.12.004]

10 Dehghan M, Malakoutikhah A, Ghaedi Heidari F, Zakeri MA. The Effect of Abdominal Massage on Gastrointestinal Functions: a Systematic Review.

2020; 54: 102553 [PMⅠD: 33183670 DOⅠ: 10.1016/j.ctim.2020.102553]

11 ?etinkaya O, Ovayolu ?, Ovayolu N. The Effect of Abdominal Massage on Enteral Complications in Geriatric Patients.

2020; 6: 2377960820963772 [PMⅠD: 35155761 DOⅠ: 10.1177/2377960820963772]

12 Mori S, Ai T, Otomo Y. Laceration of the transverse mesocolon in an old man with a habit of abdominal massage for constipation: a case report.

2020; 6: 1 [PMⅠD: 31898753 DOⅠ: 10.1186/s40792-019-0767-6]