Click below to learn more about the case.
Findings in this case: There are areas of linear low attenuation present within the pancreatic tail. There are areas in the distal body and tail demonstrate patchy enhancement. There is a high density free fluid in the upper abdomen in the subhepatic area, anterior pararenal space, around the tail of the pancreas and around the spleen consistent with blood.
Diagnosis: Pancreatic laceration with hemorrhage and early leakage of pancreatic fluid.
File: 4 C.
Organ system: 4 Hepatobiliary System
Organ: C. Pancreas
Etiology and incidence: 1) Blunt abdominal injury or penetrating injuries (stabbing or gunshot). Accounts for approximately 10% of intra-abdominal injuries. Associated with injuries to the LEFT lobe of the liver, stomach and/or mesentery. 2) Uncommonly to rarely an isolated injury. Also, consider possible iatrogenic pancreatic injury in endoscopic procedures and postsurgical patients with a surgeries in the pancreatic region. If there is an increase in fluid in the anterior pararenal space pancreatitis secondary to medications and/or injury to the pancreas should be considered in the differential diagnosis. 3) In children, the most common cause of pancreatitis is trauma. In the absence of specific history of trauma, consider abuse in the differential diagnosis.
Diagnosis: Consider possible pancreatic injury if: There are areas of low-attenuation on contrast enhanced CT. These can be linear or there can be inhomogeneous enhancement of the pancreas. Thickened pancreas.”Neighborhood” injuries to the liver, duodenum, stomach or kidney.
Increasing fluid in the anterior pararenal space.
PANCREAS INJURY GRADING SCALE
Grade Description
I Minor contusion without duct injury Superficial laceration
II Major contusion without duct injury or tissue loss. Major laceration without duct injury or tissue loss
III Distal transection or parenchymal injury with duct injury
IV Proximal transection or parenchymal injury involving ampulla
V Massive disruption of pancreatic head
Prognosis/Clinical:
Treatment: Full low grade lesions, air is most typically supportive and similar to that for a moderate pancreatitis. Higher grade injuries typically involving the pancreatic duct, require pancreatic ductal stenting, partial surgical resection of the pancreas, surgical or percutaneous drainage of pancreatic fluid collections and/or abscesses.
Treatment: Pancreatic Injury: Classification of Pancreatic Injury;Nasim Ahmed, MD, FACS and Jerome J. Vernick, MD, FACS. http://www.medscape.com/viewarticle/715637_4
Without Major Ductal Injuries (Grades I and II)
Minor contusions seen on CT scan can be managed nonoperatively. Suspicion of ductal injury requires ERCP evaluation. Continued rising serum amylase level and/or changes in serial abdominal exam may require repeat CT scan or operative intervention. Major contusions (Grade II) require only simple drainage. Frequently, grade I and II injuries can cause necrosis at the edge of the contusion site, requiring debridement and drainage.
Injuries with Major Duct Involvement (Grades III-V)
Grade III. Pancreatic injury with ductal disruption at the body or neck left of the superior mesenteric vein can be managed by performing a distal pancreatectomy. Splenic salvage can be attempted but may not be feasible in hemodynamically unstable patients.
Grade IV. Management of the pancreatic transaction to the right of the superior mesenteric vessels poses a great challenge. A distal pancreatectomy requires almost 80% of the pancreas to be removed and will lead to hyperglycemia in a majority of patients. The appropriate procedure to be performed is central debridement or resection with distal pancreatojejunostomy.
Grade V. Severe injury to the head of the pancreas may need ERCP evaluation and possible stenting of the severed proximal duct. Occasionally external drainage is the only modality required, thereby creating a controlled fistula. Pancreaticoduodenectomy is indicated only if the pancreatic head injury involves the major pancreatic duct and ampulla.
Indications for early surgery include increasing amounts of fluid/blood and devitalized/non-enhancing pancreatic tissue. Late indications for surgery include abscesses not drainable percutaneously.
Complications: Pancreatic necrosis, posttraumatic pancreatitis, pancreatic pseudocyst, abscess, fistula.
Prognosis: Depends on the associated injuries as well as complications. Mortality rates can be as high as 20 to 25%.
References:
Pancreatic Injury: Classification of Pancreatic Injury;Nasim Ahmed, MD, FACS and Jerome J. Vernick, MD, FACS.http://www.medscape.com/viewarticle/715637_4 Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling. Surg Clin N A 1995; 75:293-303.
Injury Severity Scoring. http://www.surgicalcriticalcare.net/Resources/injury_severity_scoring.pdf
MR Pancreatography: A Useful Tool for Evaluating Pancreatic Disorders Radiographics January 1999 19:5-24
Ann S. Fulcher,Mary Ann Turner
Abstract
Full Text
Full Text (PDF)
Figures Only
Pancreatic disease in children and young adults: evaluation with CT. Radiographics September 1998 18:1171-1187
D D Vaughn, A A Jabra, and E K Fishman
Abstract
Full Text (PDF)
Hemoperitoneum as the Sole Indicator of Abdominal Visceral Injuries: A Potential Limitation of Screening Abdominal US for Trauma Radiology August 1999 212:423-430
Kathirkamanathan Shanmuganathan, Stuart E. Mirvis, Caroline D. Sherbourne, William C. Chiu,
Abstract
Full Text
Full Text (PDF)
Figures Only
Diagnosis and Classification of Pancreatic and Duodenal Injuries in Emergency Radiology Radiographics October 2008 28:1591-1602; doi:10.1148/rg.286085524
Ulrich Linsenmaier, Stefan Wirth, Maximilian Reiser, and Markus Körner
Abstract
Full Text
Full Text (PDF)
Figures Only
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
…the same day showed no injury to the pancreatic duct. The patient recovered…the pancre-atic Avneesh Gupta, Joshua W. Stuhlfaut, Keith W. Fleming, Brian C. Lucey, and Jorge A. Soto
Abstract
Full Text
Full Text (PDF)
Figures Only
Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation Radiology June 2002 223:603-613; Published online April 19, 2002, doi:10.1148/radiol.2233010680
Emil J. Balthazar
Abstract
Full Text
Full Text (PDF)
Figures Only
