Pancreatic Trauma

No Results

No Results

processing….

Pancreatic injury is a relative enigma, even in modern medical practice with technology and advanced diagnostic methods. Although initially hard to diagnose, most minor pancreatic injuries are relatively easy to treat. However, a delayed diagnosis of pancreatic injury, mild or severe, is easy to diagnose but becomes a major therapeutic challenge to the medical team and a potentially disastrous situation for the patient.

The pancreas, sitting in a relatively protected position high in the retroperitoneum, is infrequently injured in typical blunt injuries (eg, from motor vehicle crashes) compared with its splenic and hepatic counterparts. Accordingly, many blunt pancreatic injuries are not immediately recognized and consequently end up causing higher morbidity and mortality rates than observed in injuries to other intraperitoneal organs. [1]

Conversely, penetrating abdominal trauma—by its very nature usually mandating emergency exploration—more frequently includes pancreatic injury. But even physical visualization and examination of the pancreas in the operating room may miss an isolated ductal injury to the pancreas without adjunctive tests.

This article summarizes the findings commonly associated with pancreatic injury, available diagnostic modalities and their sensitivities, and treatment issues and options.

The overall rate of blunt pancreatic injury observed in level 1 trauma centers is rather low compared with other injuries. The pancreas is estimated to be the 10th most injured organ compared to other organs (eg, brain, spleen, liver). To consider a pancreatic injury, a trauma that occurred from a significant force is usually required. The incidence of diagnosed pancreatic injury is expected to be higher at a trauma center specializing in serious injury than at a community hospital. Of 100 patients with blunt trauma, fewer than 10 will have a documented pancreatic injury.

The incidence of pancreatic injury in patients with a penetrating trauma is much higher. Gunshot wounds (GSWs); shotgun injuries; and stabbings to the back, flank, and abdomen (defined as level to inguinal ligament) frequently include pancreatic injury, occurring in approximately 20-30% of all patients with penetrating traumas. [2] This occurrence elicits another key point in pancreatic trauma: Because the blunt force required to injure the pancreas is so significant and penetrating trauma usually injures multiple organs, a pancreatic injury is rarely a solitary injury. When the pancreas is injured, with the possible exception of child abuse or the well-placed stab in the back, the physician or surgeon can be confident that other organs are also affected. Therefore, multiple organ injury is a red flag suggesting the possibility of a pancreatic injury.

Because of its anatomic position (see Relevant Anatomy), an isolated pancreatic injury may occur with penetrating trauma to the mid back in the form of stab wounds or impalement. In a blunt trauma–induced isolated pancreatic injury, fracture over the spinal column is usually observed in smaller children and is caused by direct abdominal blows from malpositioned seat belts or intentional child abuse. Fortunately, both of these situations are relatively rare.

Usually, penetrating trauma caused by firearms results in the highest frequency of pancreatic injury and is almost always associated with concurrent injury to other intra-abdominal organs. This injury can result in a relatively simple isolated puncture of the body or tail of the pancreas (a highly complex and difficult injury) or an injury to the pancreatic head with involvement of the biliary and pancreatic ductal systems. In addition, the proximity of the larger vessels (eg, portal vein), the abdominal aorta, and the inferior vena cava (IVC) to the pancreatic head increases the risk of exsanguinating accompanying pancreatic penetrating injury. Exsanguinating due to concomitant vascular injury accounts for the greatest number of deaths in patients with pancreatic injury.

Unlike the spleen, few data suggest that preexisting primary or secondary diseases of the pancreas result in a higher risk of injury or a higher mortality rate when the pancreas is injured. Clearly, preexisting severe pancreatitis or diabetes mellitus negatively affects the overall mortality and morbidity rates in patients with pancreatic trauma, but few published data support this commonly held clinical view.

However, the postinjury development of pancreatitis or diabetes mellitus is a different issue. The development of either of these conditions after injury is associated with a significant increase in morbidity and overall mortality rates in patients who experience trauma.

The type of injury (ie, blunt vs penetrating) and information about the injuring agent (eg, GSW, knife) help focus the clinician on the possibility of pancreatic injury.

During the physical examination, seat belt marks, flank ecchymoses, or penetrating injuries should alert the physician to the potential for pancreatic injury. Pancreatic injury can be frighteningly symptom free early in the postinjury time frame and even silent in many cases. Rarely, a contained fracture of the spleen with retroperitoneal hematoma or leak manifests as dull epigastric pain or back pain, but the more common scenario is for patients to exhibit severe peritoneal irritation and a positive abdominal examination finding, usually caused by injury to other organs. Symptoms of injury to other structures commonly mask or supersede that of pancreatic injury, both early and late in the hospital course. Therefore, a high degree of clinical awareness is necessary to ensure that pancreatic injuries are not overlooked or missed, either early in the course of trauma or later in the ICU when the patient is not clinically improving as expected.

CT scan findings of pancreatic trauma are generally categorized as direct signs (eg, pancreatic laceration) that tend to be specific but lack sensitivity and indirect signs (eg, peripancreatic fluid) that tend to be sensitive but lack specificity. [3]

In patients experiencing blunt trauma, CT scans provide the best overall method for diagnosis and recognition of a pancreatic injury. Retroperitoneal hematoma, retroperitoneal fluid, free abdominal fluid, and pancreatic edema frequently accompany injuries to the pancreas.

In patients with penetrating trauma, visualization of perforation, hemorrhage or fluid leak (eg, bile, pancreatic fluid), or retroperitoneal hematoma around the pancreas suggests the need for further evaluation.

In cases in which the CT scan findings are indefinite or clinical suspicion of a pancreatic injury remains, further investigation with magnetic resonance cholangiopancreatography (MRCP) may be used. Although injury of the main pancreatic duct may be strongly suggested upon initial CT scanning, MRCP can demonstrate clear delineation of the duct and its integrity. [3]

Located in a relatively protected area of the abdominal cavity, the pancreas is high and posteriorly situated in a fixed retroperitoneal position. The rib cage provides a bony structural protection, in addition to the protection afforded by the thick dorsal muscle groups (paraspinous). Anteriorly, the mature adult rectus and abdominal muscles, combined with the energy-absorbing characteristics of the liver, colon, duodenum, stomach, and small bowel, provide physiologic padding that protects the pancreas from blunt injury. In severe blunt trauma, the anatomic position may result in injury (eg, fracture of the body over the spinal column and vertebral bodies posteriorly). However, the anatomic position of the pancreas neither protects nor increases the risk from penetrating injury.

The proximity of vascular structures to the head of the pancreas has a marked effect on the morbidity and mortality rates of patients who experience a pancreatic injury. The subhepatic IVC and the aorta sit just posterior to the pancreatic head to the patient’s right side, and the superior mesenteric vein coalesces into the portal vein immediately behind the pancreas. Exsanguinating hemorrhage from concurrent injury to these vessels is a frequent cause of death in patients with a pancreatic injury.

The splenic artery (off the celiac trunk) and vein (draining into the portal vein) run superior and posterior to the body and tail of the pancreas and are relatively easier to expose and control compared to the IVC and portal vein. The vascular anatomy that causes such difficulty in repairing injuries to the head of the pancreas actually makes injuries to the body and tail easier to manage.

No absolute contraindications exist for pancreatic exploration or resection in patients who are experiencing trauma. The presence of hypothermia, dilutional coagulopathy, and other fatal or near-fatal injuries obviously influences the surgeon’s to use damage-control techniques versus operative repair or resection. A trauma surgeon may explore and widely drain, perform a segmental resection, or even, very rarely, perform a trauma Whipple procedure (pancreatic duodenectomy) initially or in delayed fashion, depending on the presence of other injuries and the physiologic condition of the patient.

Ahmed N, Vernick JJ. Pancreatic injury. South Med J. 2009 Dec. 102(12):1253-6. [Medline].

Nikeghbalian S, Akrami M, Fazelzadeh A. Late development of pancreatitis following gunshot trauma, a case report. Iran Red Crescent Med J. 2012 Sep. 14(9):584-6. [Medline]. [Full Text].

Rekhi S, Anderson SW, Rhea JT, Soto JA. Imaging of blunt pancreatic trauma. Emerg Radiol. 2010 Jan. 17(1):13-9. [Medline].

Almaramhy HH, Guraya SY. for pancreatic injuries in pediatric blunt abdominal trauma. World J Gastrointest Surg. 2012 Jul 27. 4(7):166-70. [Medline]. [Full Text].

Sheikh F, Fallon S, Bisset G, Podberesky D, Zheng J, Orth R, et al. Image-guided prediction of pseudocyst formation in pediatric pancreatic trauma. J Surg Res. 2015 Feb. 193(2):513-8. [Medline].

Panda A, Kumar A, Gamanagatti S, Bhalla AS, Sharma R, Kumar S, et al. Evaluation of diagnostic utility of multidetector and magnetic resonance imaging in blunt pancreatic trauma: a prospective study. Acta Radiol. 2014 Apr 23. [Medline].

Cuenca AG, Islam S. Pediatric pancreatic trauma: trending toward nonoperative management?. Am Surg. 2012 Nov. 78(11):1204-10. [Medline].

Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg. 2003 Mar. 38(3):354-7; discussion 354-7.

Akhrass R, Yaffe MB, Brandt CP. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. 1997 Jul. 63(7):598-604. [Medline].

Asensio JA, Demetriades D, Hanpeter DE et al. Management of pancreatic injuries. Curr Probl Surg. 1999 May. 36(5):325-419. [Medline].

Bradley EL 3rd, Young PR Jr, Chang MC. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg. 1998 Jun. 227(6):861-9. [Medline].

Chen ZB, Zhang Y, Liang ZY, et al. Incidence of unexplained intra-abdominal free fluid in patients with blunt abdominal trauma. Hepatobiliary Pancreat Dis Int. 2009 Dec. 8(6):597-601. [Medline].

Clements RH, Reisser JR. Urgent endoscopic retrograde pancreatography the stable trauma patient. Am Surg. 1996 Jun. 62(6):446-8. [Medline].

Cohen DB, Magnotti LJ, Lu Q, et al. Pancreatic duct ligation reduces lung injury following trauma and hemorrhagic shock. Ann Surg. 2004 Nov. 240(5):885-91.

Craig MH, Talton DS, Hauser CJ. Pancreatic injuries from blunt trauma. Am Surg. 1995 Feb. 61(2):125-8. [Medline].

Fabian TC. Infection in penetrating abdominal trauma: risk factors and preventive antibiotics. Am Surg. 2002 Jan. 68(1):29-35.

Farrell RJ, Krige JE, Bornman PC. Operative strategies in pancreatic trauma. Br J Surg. 1996 Jul. 83(7):934-7. [Medline].

Firstenberg MS, Volsko TA, Sivit C. Selective management of pediatric pancreatic injuries. J Pediatr Surg. 1999 Jul. 34(7):1142-7. [Medline].

Fischer JH, Carpenter KD, O’Keefe GE. CT diagnosis of an isolated blunt pancreatic injury. AJR Am J Roentgenol. 1996 Nov. 167(5):1152. [Medline].

Gorecki PJ, Cottam D, Angus LD, Shaftan GW. Diagnostic and therapeutic laparoscopy for trauma: a technique of safe and systematic exploration. Surg Laparosc Endosc Percutan Tech. 2002 Jun. 12(3):195-8.

Graham JM, Mattox KL, Jordan GL Jr. Traumatic injuries of the pancreas. Am J Surg. 1978 Dec. 136(6):744-8. [Medline].

Gupta A, Stuhlfaut JW, Fleming KW, et al. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. 2004 Sep-Oct. 24(5):1381-95. [Medline].

Ilahi O, Bochicchio GV, Scalea TM. Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study. Am Surg. 2002 Aug. 68(8):704-7; discussion 707-8.

Jones RC. Management of pancreatic trauma. Am J Surg. 1985 Dec. 150(6):698-704. [Medline].

Kealey WD, Garstin WI, Diamond T. Transection of the pancreatic head following blunt abdominal trauma. Br J Clin Pract. 1995 May-Jun. 49(3):158-9. [Medline].

Kouchi K, Tanabe M, Yoshida H. Nonoperative management of blunt pancreatic injury in childhood. J Pediatr Surg. 1999 Nov. 34(11):1736-9. [Medline].

Leppaniemi AK, Haapiainen RK. Risk factors of delayed diagnosis of pancreatic trauma. Eur J Surg. 1999 Dec. 165(12):1134-7. [Medline].

Madiba TE, Mokoena TR. Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas. Br J Surg. 1995 Sep. 82(9):1236-9. [Medline].

Mayer JM, Tomczak R, Rau B, et al. Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome. Dig Surg. 2002. 19(4):291-7; discussion 297-9.

McGahren ED, Magnuson D, Schaller RT. Management of transected pancreas in children. Aust N Z J Surg. 1995 Apr. 65(4):242-6. [Medline].

Nwariaku FE, Terracina A, Mileski WJ et al. Is octreotide beneficial following pancreatic injury?. Am J Surg. 1995 Dec. 170(6):582-5. [Medline].

Olah A, Issekutz A, Haulik L, Makay R. Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management. Dig Surg. 2003. 20(5):408-14.

Patton JH Jr, Lyden SP, Croce MA. Pancreatic trauma: a simplified management guideline. J Trauma. 1997 Aug. 43(2):234-9; discussion 239-41. [Medline].

Procacci C, Graziani R, Bicego E. Blunt pancreatic trauma. Role of CT. Acta Radiol. 1997 Jul. 38(4 Pt 1):543-9. [Medline].

Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR. 2004 Apr. 25(2):180-204.

Smith DR, Stanley RJ, Rue LW 3rd. Delayed diagnosis of pancreatic transection after blunt abdominal trauma. J Trauma. 1996 Jun. 40(6):1009-13. [Medline].

Takishima T, Sugimoto K, Hirata M. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg. 1997 Jul. 226(1):70-6. [Medline].

Timberlake GA. Blunt pancreatic trauma: experience at a rural referral center. Am Surg. 1997 Mar. 63(3):282-6. [Medline].

Tyburski JG, Dente CJ, Wilson RF, et al. Infectious complications following duodenal and/or pancreatic trauma. Am Surg. 2001 Mar. 67(3):227-30; discussion 230-1.

Vasquez JC, Coimbra R, Hoyt DB, Fortlage D. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury. 2001 Dec. 32(10):753-9.

Wind P, Tiret E, Cunningham C. Contribution of endoscopic retrograde pancreatography in management of complications following distal pancreatic trauma. Am Surg. 1999 Aug. 65(8):777-83. [Medline].

Wolf A, Bernhardt J, Patrzyk M, Heidecke CD. The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma. Surg Endosc. 2005 May. 19(5):665-9.

Wong YC, Wang LJ, Lin BC. CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation. J Comput Assist Tomogr. 1997 Mar-Apr. 21(2):246-50. [Medline].

Wright MJ, Stanski C. Blunt pancreatic trauma: a difficult injury. South Med J. 2000 Apr. 93(4):383-5. [Medline].

Young PR Jr, Meredith JW, Baker CC. Pancreatic injuries resulting from penetrating trauma: a multi- institution review. Am Surg. 1998 Sep. 64(9):838-43; discussion 843-4. [Medline].

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners for Children; Physical Sciences Inc, Mediwound.

John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale- Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas

Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Pancreatic Trauma

Research & References of Pancreatic Trauma|A&C Accounting And Tax Services
Source

42 thoughts on “Pancreatic Trauma”


Leave a Reply