Case of the week: pancreatic injury

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Findings:

1. There is a transverse lucency present within the area of the mid to distal body of the pancreas.
2. There is a large amount of fluid present around the pancreas and extending into the retroperitoneum and anterior pararenal space on the LEFT.  A small amount of this fluid extends into the LEFT paracolic gutter.
3. Additionally, there is an aortic injury which is not well evaluated on these images.

Diagnosis:

1. Pancreatic laceration with peripancreatic fluid and blood. 
2. Aortic injury noted secondarily.

Additional Information:

File:4C
Organ system: 4.0  Hepatobiliary System
Organ: C. – Pancreas

Etiology and incidence: 1) Occurs secondary to blunt or sharp trauma to the abdomen. 2) Occurs at up to 10% of abdominal injuries.

Diagnosis:

1. CT scan with contrast is the best examination for the most definitive diagnosis.
   1. The gland may or may not be enlarged.  The enlargement can be focal or more diffuse when it is present.
   2. There is fluid in the peripancreatic space extending into the anterior pararenal spaces typically.  The fluid may be of relatively low to higher mean density secondary to the presence of pancreatic fluid and/or blood.
   3. Lacerations appear as areas of low attenuation within the pancreatic parenchyma.  This is only seen on enhanced images.  More prominent areas of low attenuation may represent pancreatic infarction.
   4. More prominent pancreatic injuries consist of transaction and fracture.  More prominent areas of low density are present with potentially separation of the gland.  This more commonly occurs through the pancreatic neck.
   5. Areas of pancreatic contusion can be seen as areas of rounded or patchy low-attenuation with the pancreatic parenchyma.
   6. Secondary acute, posttraumatic pancreatitis can occur.  Findings are similar to that with more typical pancreatitis with low attenuation and possible pancreatic necrosis.
   7. Associated injuries: Aorta, LEFT lobe of the liver, duodenum and kidney.
2. Ultrasound will may times be difficult to interpret or done diagnostic due to the presence of air in the region around the pancreas from ileus or distended stomach.  When findings are present, it is potentially possible to see fluid in the peri-pancreatic region.  It is unlikely to see the area of laceration.  Findings otherwise would be secondary to pancreatitis.
3. MRI is of limited assistance in the patient with multi-trauma.  Findings on MRI would be more consistent with those seen with pancreatitis.  M.R.C.P. can be performed however which may be able to evaluate the main pancreatic duct.
4. Pancreatic injury grading scale:

 AAST classification of pancreatic trauma.

Prognosis/Clinical: 1) Depending upon the degree of injury, the patient may develop post traumatic pancreatitis and/or pancreatic necrosis.  Pancreatic pseudo cysts, pancreatic abscesses and fistulas can occur. 2) Mortality has been reported as up to 20%.

References:
Journal of the American College of Surgeons
Volume 207, Issue 5 , Pages 646-655, November 2008
American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, Liver, and Kidney, Validation Based on the National Trauma Data Bank

Glen Tinkoff, MD, FACS Thomas J. Esposito, James Reed, PhD Patrick Kilgo, PhD John Fildes, MD, FACS Michael Pasquale, MD, FACS J. Wayne Meredith, MD, FACS
Abstract  
Full Text  
PDF 
References

Background: This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB).

Study Design: All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred.

Results: There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale–coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p ≤ 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p ≤ 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades.

Conclusions: This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Classification of liver and pancreatic trauma
Gabriel C. Oniscu, Rowan W. Parks, and O. James Garden, Regius Professor of Surgery
Department of Surgery, University of Edinburgh, Edinburgh, UK
O. James Garden, Department of Surgery, University of Edinburgh, Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK, Phone: +44 (0) 131 242 3614, Fax: +44 (0) 131 242 3617, Email: O.J.Garden@ed.ac.uk .

Corresponding author.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2131370/ 

Abstract: The liver is the most frequently injured intra-abdominal organ and associated injury to other organs increases the risk of complications and death. This has highlighted the critical need for an accurate classification system as a basis for the clinical decision-making process. Several classification systems have been proposed in an attempt to incorporate the aetiology, anatomy and extent of injury and correlate it with subsequent clinical management and outcome. The widely accepted Organ Injury Scale is based on anatomical criteria that quantify the disruption of the liver parenchyma and defines six groups which may influence management strategies and relate to outcome. The less common pancreatic injury remains a major source of morbidity and mortality due to the likelihood of associated solid or hollow-organ injuries. The implication of a delay in diagnosis and management emphasizes the need for an accurate classification system. The Organ Injury Scale is widely used for pancreas trauma and recognizes the importance of progressive parenchymal injury and in particular ductal injury. Advances in imaging techniques have led to the development of newer radiological classification systems; however, validation of their accuracy remains to be proven. An accurate classification of liver and pancreatic trauma is fundamental for the development of treatment protocols in which clinical decisions are based on the severity of injury.

Avneesh Gupta, Joshua W. Stuhlfaut, Keith W. Fleming, Brian C. Lucey, and Jorge A. Soto
Blunt Trauma of the Pancreas and Biliary Tract: A Multimodality Imaging Approach to Diagnosis
Radiographics September 2004 24:1381-1395; doi:10.1148/rg.245045002
…RadioGraphics Conclusions Pancreatic and biliary injuries due to blunt trauma are uncommon but…the assessment of pancreatic duct trauma and its sequelae…Sepulveda ME, Perez JM. Traumatic disruption of the pancreatic duct: diagnosis with…
Abstract
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C J Sivit, G A Taylor, D I Bulas, L M Bowman, and M R Eichelberger
Blunt trauma in children: significance of peritoneal fluid.
Radiology January 1991 178:185-188
Abstract
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Mehran Fotoohi, Horacio B. D’Agostino, Bruce Wollman, Kenneth Chon, Seyed Shahrokni, and Eric vanSonnenberg
Persistent Pancreatocutaneous Fistula after Percutaneous Drainage of Pancreatic Fluid Collections: Role of Cause and Severity of Pancreatitis
Radiology November 1999 213:573-578
Abstract
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Ulrich Linsenmaier, Stefan Wirth, Maximilian Reiser, and Markus Körner
Diagnosis and Classification of Pancreatic and Duodenal Injuries in Emergency Radiology
Radiographics October 2008 28:1591-1602; doi:10.1148/rg.286085524
…Wan JM. CT of blunt pancreatic trauma: a pictorial essay…Computed tomography of pancreatic trauma. Radiology 1983; 147…emergency radiology. | Pancreatic and duodenal injuries after blunt abdominal trauma are rare; however, delays…
Abstract
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