Endocrine Abstracts

A 43-year-old gentleman with no known medical illnesses presented with progressive abdominal distension and pain. This happened following a fall from 2-metre height with direct impact on his abdomen. On examination he had signs of abdominal peritonism and was managed as a trauma case. He was haemodynamically stable. CT of his abdomen showed suspected large pancreatic haematoma, consistent with significant pancreatic injury with no evidence of active haemorrhage or pancreatitis. However, he had left the hospital before further evaluation and was brought to the hospital 48 hours later with confusion and tachypnoea. Repeat CT scan showed similar appearances of the suspected pancreatic injuries. However, he was found to be in severe diabetic ketoacidosis with glucose 34.4 mmol/l , pH 6.94 and ketones 6 mmol/l . Lactate was 1.5 mmol/l . Serial amylase was within the normal range. Following aggressive medical therapy, his ketoacidosis had resolved and glucose improved significantly within 12 hours. The pancreatic injury was managed conservatively. Further correlation with MRCP was inconclusive but it was suggested that the pancreatic duct had been transected in the neck of the gland. HbA1c during admission was 86 mmol/mol indicating background of undiagnosed diabetes mellitus. He was discharged with Metformin, Gliclazide and Dapagliflozin and repeated HbA1c 6 weeks later showed significant improvement to 64 mmol/mol.

Discussion: This case illustrates the unmasking of diabetes mellitus presenting as severe DKA secondary to severe pancreatic injury with no evidence of pancreatitis. This could have happened due to the transient loss of endocrine pancreatic function resulting in absolute insulin deficiency. This gentleman has type 2 diabetes with good initial response to oral anti-hypoglycaemics.

Conclusion: Thorough medical evaluation for possible hyperglycaemic emergencies should be performed in patients with significant intra-abdominal injury, as this could be missed due to priority given to the trauma itself.