Traumatic pancreatic injury

School ager
hit by a car while riding their bike. Axial CT with contrast of the abdomen (above) shows a near-complete transection of the pancreatic body along with a large amount of free fluid deep in the pelvis (below)The diagnosis was transection of the pancreatic body.
pediatricimaging.org • CC-by-nc-sa 4.0
Pancreatic
trauma • Complex polytrauma with pancreas, duodenal, colonic, and vascular injuries - Ganzer Fall bei Radiopaedia
Hartung M, Complex polytrauma with pancreas, duodenal, colonic, and vascular injuries. Case study, Radiopaedia.org (Accessed on 15 Sep 2023) https://doi.org/10.53347/rID-75897 • CC by-nc-sa 3.0 (modified)
School ager
who fell off a table and then had the table fall on to them. Axial CT with contrast of the abdomen shows a heterogenous appearance to the pancreatic head (middle left and below left) which is also appreciated on the coronal image (above right) just medial to the contrast filled duodenum. There was a large amount of free fluid in the pelvis (below right)The diagnosis was contusion of the pancreatic head.
pediatricimaging.org • CC-by-nc-sa 4.0
Teenager in a
motor vehicle accident. Axial CT with contrast of the abdomen shows a low density fluid-filled structure just to the left of midline and posterior to the body of the pancreas.The diagnosis was right pancreatic pseudocyst after pancreatic trauma.
pediatricimaging.org • CC-by-nc-sa 4.0
Pancreatic
pseudocyst • Post-traumatic pseudocyst of the pancreas (abdominal radiograph) - Ganzer Fall bei Radiopaedia
Niknejad M, Post-traumatic pseudocyst of the pancreas (abdominal radiograph). Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-23572 • CC by-nc-sa 3.0 (modified)
Radiopaedia • CC-by-nc-sa 3.0 • de

The pancreas is uncommonly injured in blunt trauma. However, pancreatic trauma has a high morbidity and mortality rate. Imaging features range from subtle to obvious.

Epidemiology

The pancreas is injured in ~7.5% (range 2-13%) of blunt trauma cases . Motor vehicle accidents account for the vast majority of cases.

Clinical presentation

The classic triad of fever, raised white cell count, and amylase is rare. Serum amylase or lipase are elevated in ~80% of cases  but distinguishing between a raised amylase or lipase as an acute phase reactant or resulting from a pancreatic injury is difficult.

Pathology

The pancreatic body accounts for two-thirds of injuries with ~10% occurring each in the head, neck and tail .

The pancreas is prone to crush injuries of the vertebral column :

  • pancreatic laceration: partial thickness tear of the pancreas
  • pancreatic transection: full thickness tear of the pancreas
  • pancreatic comminution (fracture): shattered pancreas
  • pancreatic hematoma
  • pancreatic pseudocyst
Grading

See main article: grading of pancreatic injuries.

Associations

It is uncommonly (<10%) an isolated injury and other organs that are also injured include:

Radiographic features

Fluoroscopy
  • ERCP can also be used to image the pancreatic duct and any associated injury, although it's main role is to provide access to stent the pancreatic duct when injury is confirmed by MRCP
CT
  • direct signs
    • hypodense laceration or comminution of the pancreatic parenchyma
    • heterogeneous parenchymal enhancement
    • enlargement of the pancreas
    • fluid collections (pseudocyst, abscess or hematoma) communicating with the pancreatic duct
  • secondary signs
    • peripancreatic fat stranding, fluid or hematoma between the pancreas and splenic vein
    • peripancreatic fluid
    • thickening of Gerota’s fascia
  • injury to the pancreatic duct may not be seen directly but is inferred by the grading of the injury
MRI
  • MRCP can be used to image the pancreatic duct and any associated injury

Treatment and prognosis

Delayed diagnosis raises both the mortality and morbidity of traumatic pancreatic injuries, both of which are high, with a mortality rate of up to 20% .

Injuries with pancreatic duct disruption are more likely to undergo endoscopic stenting whereas surgical intervention is preferred for injuries not involving the pancreatic duct .

Complications

Complications of pancreatic trauma occur in up to 20% of patients and include:

  • pancreatitis: occurs in ~7.5% (range 6-10%)
  • fistula (more common with pancreatic duct disruption)
  • abscess and sepsis (more common with pancreatic duct disruption)
  • hemorrhage
  • pancreatic pseudocyst

Differential diagnosis

Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu Pankreastrauma:
stumpfes
Bauchtrauma
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