GI Radiology > Pancreas > Trauma

Trauma

Traumatic injury to the pancreas is rare and difficult to diagnose. Pancreatic injuries are present in 2% of closed abdominal trauma, far behind injuries to the liver and spleen (47 and 44% respectively). Vehicle accidents (involving abdominal impact against the steering column) are the most common cause of pancreatic trauma. During violent trauma, the pancreas is crushed against the vertebrae (L1). In order of frequency, injuries to the pancreas involve the body, head, and tail. These injuries are rarely isolated; 60% are duodenopancreatic lesions, while 90% involve at least one other abdominal organ.

During the initial evaluation, the symptoms of an isolated pancreatic lesion are often absent. Patients with early symptoms may report brief post-traumatic epigastric pain that has completely subsided. Pain may be absent for several days, even in the case of complete transaction with avulsion of the pancreatic duct. In isolated pancreatic lesions, the clinical manifestations may only appear with late complications, such as pseudocysts, abcesses, etc. Laboratory values are not very specific; the increase in serum and urine amylase levels can be delayed and non-specific. The presence of amylase in peritoneal lavage is indicative of pancreatic injury; its absence does not exclude injury, however. In view of the above, the history and mechanism of the impact often constitute the only criteria for suspecting the diagnosis.

Common complications of pancreatic trauma include fistulas, pseudocysts, abcesses, and early pancreatitis. Fistulas are not always considered a complication since they may prevent the formation of pseudocysts (by providing a pathway for pancreatic enzyme drainage). Pseduoaneurysms of the pancreaticoduodenal arteries, secondary hemorrhage, and recurrent pancreatitis occur more rarely.

Anatomic lesions are classified according to the damage to the parenchyma and ductal system. There are several classification systems; the table below lists one such system.

Classification of Pancreatic Trauma by Jeffrey et al.

Grade Description
I Simple contusion of the parenchyma or small hematoma, without capsular rupture.
II Small fractures and hematomas without any injury to the pancreatic duct.
III Clean cut section of the pancreas involving more than 50% of its thickness with rupture of the pancreatic duct.
IV Crushing of the entire pancreatic gland.
Jeffrey et al. Pancreas, retroperitoneal duodenum, colon, and vascular trauma. In: McCorrt JJ (ed) Trauma Radiology. Churchill Livingston, NY pp 215-230

Imaging:

Intravenous contrast-enhanced CT is the best modality for the evaluation of pancreatic trauma. Enteral contrast is also used to highlight the duodenum, which facilitates the evaluation of the head of the pancreas. Fractures of the pancreas are generally very thin, and the parenchyma itself shows no changes in density. Substantial peripancreatic hematomas may be present in cases of damage to the great vessels, notably the splenic artery and vein.

Pneumoretroperitoneum in the right anterior pararenal space suggests duodenal rupture, and is indicative of significant retroperitoneal trauma.

US is better suited for follow-up evaluation of proven lesions (rather than original diagnosis). Fractures of the pancreas can be visualized with US; along with possible complications (acute pancreatitis, etc.).


Pancreatic laceration

ERCP may also assist in diagnosis of pancreatic trauma. It evaluates the integrity of the pancreatic duct, and identifies injuries that require surgical correction. ERCP is indicated in cases of high clinical suspicion but negative CT findings.


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