Imaging of blunt pancreatic trauma

Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm

BACKGROUND

The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members.

METHODS

Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed.

RESULTS

The algorithm is attached with detailed explanation of each step, supported by data if available.

CONCLUSION

Blunt pancreatic trauma is rare and presents many treatment challenges.

Use of MR in Pancreaticobiliary Emergencies

This article presents the MR protocols, imaging features, diagnostic criteria, and complications of commonly encountered emergencies in pancreaticobiliary imaging, which include pancreatic trauma, bile leak, acute cholecystitis, biliary obstruction, and pancreatitis. Various classifications and complications that can arise with these conditions, as well as artifacts that may mimic pathology, are also included. Finally, the emerging utility of abbreviated MR protocols is discussed.

Minimally Invasive Approaches for Traumatic Rupture of the Pancreas in Children—A Case Series

Pancreatic trauma in children is rare; therefore, both scientific knowledge and clinical experience regarding its management are limited. Abdominal sonography and subsequent computed tomography (CT) imaging are the diagnostic mainstay after severe abdominal trauma in many pediatric trauma centers. However, the diagnosis of pancreatic injury is missed on the initial imaging in approximately one third of cases, with even higher numbers in young children. While conservative treatment is preferred in low-grade injuries, surgical interventions may be indicated in more severe injuries. We present a case series including four patients with high-grade pancreatic injury. Two patients were treated surgically with open laparotomy and primary suture of the head of the pancreas and pancreatico-enterostomy, one patient underwent endoscopic stenting of the pancreatic duct and one received conservative management including observation and secondary endoscopic treatment. We want to emphasize the fact that using a minimally invasive approach can be a feasible option in high-grade pancreatic injury in selected cases. Therefore, we advocate the necessity of fully staffed and equipped high-level pediatric trauma centers.

Dual-Energy CT in the Pancreas

Dual-energy computed tomography (DECT) is an evolving imaging technology that is gaining popularity, particularly in different abdominopelvic applications. Essentially, DECT uses two energy spectra simultaneously to acquire CT attenuation data which is used to distinguish among structures with different tissue composition. The wide variety of reconstructed image data sets makes DECT especially attractive in pancreatic imaging. This article reviews the current literature on DECT as it applies to imaging the pancreas, focusing on pancreatitis, trauma, pancreatic ductal adenocarcinoma, and other solid and cystic neoplasms. The advantages of DECT over conventional CT are highlighted, including improved lesion detection, radiation dose reduction, and enhanced image contrast. Additionally, data exploring the ideal protocol for pancreatic imaging using DECT is reviewed. Finally, limitations of DECT in pancreatic imaging as well as recommendations for future research are provided.

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers

BACKGROUND

Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers.

METHODS

This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity.

RESULTS

Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury.

CONCLUSION

Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system.

LEVEL OF EVIDENCE

Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

CT-US fusion imaging increases the feasibility of early ultrasound-guided percutaneous intervention of local drug therapy in pancreatic contusion and laceration

Background

Multimodal fusion imaging (MMFI) was usually used to assist percutaneous procedures for difficult lesions, with most applications occurring with hepatic and prostatic interventions. This paper aimed to evaluate the precision and effectiveness of computed tomography-ultrasound (CT-US) fusion imaging (CUFI)-assisted US-guided percutaneous intervention (UGPI) in early local drug therapy for pancreatic contusion and laceration (PCL).

Methods

A total of 12 pigs with PCL were randomly divided into a CUFI-assisted UGPI (MU) group (n=6) and a single UGPI (SU) group (n=6). The MU group underwent CUFI-assisted UGPI of locally applied medical protein glue (1 mL) injection while the SU group received the same therapy using two-dimensional UGPI. The duration and accuracy of each procedure were observed in the 2 groups.

Results

In the MU group, the overall time of the procedure for locking the plane was 1.85±0.06 minutes. Less time was spent in the selection of the pathway and puncture site in the MU group compared with the SU group (6.56±0.42 vs. 7.61±0.44 minutes, P<0.01). The duration of puncturing and drug injection was also shorter in the MU group than in the SU group (3.41±0.30 vs. 4.20±0.20 minutes, P<0.01) and the MU group had a higher accuracy of medical protein glue injection than the SU group (100% vs. 50%, P<0.05).

Conclusions

CUFI could increase the precision and effectiveness of early UGPI in the delivery of local drug therapy in PCL.

Traumatic pancreatitis

Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.

Dual-Energy CT: A Paradigm Shift in Acute Traumatic Abdomen

Abdominal trauma, one of the leading causes of death under the age of 45, can be broadly classified into blunt and penetrating trauma, based on the mechanism of injury. Blunt abdominal trauma usually results from motor vehicle collisions, fall from heights, assaults, and sports and is more common than penetrating abdominal trauma, which is usually seen in firearm injuries and stab wounds. In both blunt and penetrating abdominal trauma, an optimized imaging approach is mandatory to exclude life-threatening injuries. Easy availability of the portable ultrasound in the emergency department and trauma bay makes it one of the most commonly used screening imaging modalities in the abdominal trauma, especially to exclude hemoperitoneum. Evaluation of the visceral and vascular injuries in a hemodynamically stable patient, however, warrants intravenous contrast-enhanced multidetector computed tomography scan. Dual-energy computed tomography with its postprocessing applications such as iodine selective imaging and virtual monoenergetic imaging can reliably depict the conspicuity of traumatic solid and hollow visceral and vascular injuries.

Imaging of Blunt Pancreatic Trauma: A Systematic Review

PURPOSE

Despite several published reports on the value of imaging in acute blunt pancreatic trauma, there remains a large variability in the reported performance of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The purpose of this study is to present a systematic review on the utility of these imaging modalities in the acute assessment of blunt pancreatic trauma. In addition, a brief overview of the various signs of pancreatic trauma will be presented.

METHODS

Keyword search was performed in MEDLINE, EMBASE, and Web of Science databases for relevant studies in the last 20 years (1999 onward). Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on the effectiveness of imaging modality (US, CT, or MRI) in detecting blunt pancreatic trauma.

RESULTS

After initial search of 743 studies, a total of 37 studies were included in the final summary. Thirty-six studies were retrospective in nature. Pancreatic injury was the primary study objective in 21 studies. Relevant study population varied from 5 to 299. Seventeen studies compared the imaging findings against intraoperative findings. Seven studies performed separate analysis for pancreatic ductal injuries and 9 studies only investigated ductal injuries. The reported sensitivities for the detection of pancreatic injuries at CT ranged from 33% to 100% and specificity ranged from 62% to 100%. Sensitivity at US ranged from 27% to 96%. The sensitivity at MRI was only reported in 1 study and was 92%.

CONCLUSION

There remains a large heterogeneity among reported studies in the accuracy of initial imaging modalities for blunt pancreatic injury. Although technological advances in imaging equipment would be expected to improve accuracy, the current body of literature remains largely divided. There is a need for future studies utilizing the most advanced imaging equipment with appropriately defined gold standards and outcome measures.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Endoscopic Management of Acute Biliopancreatic Disorders

PURPOSE

Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders.

METHODS

Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders.

RESULTS

Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders.

DISCUSSION

Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.

The use of MRI digital subtraction technique in the diagnosis of traumatic pancreatic injury

Traumatic pancreatic injuries are relatively uncommon in the setting of trauma, however, early detection of these injuries can alter patient management and overall prognosis. Computed tomography is the first line imaging modality in major trauma. Because failure to recognize pancreatic or main pancreatic duct injuries can lead to mismanagement, magnetic resonance imaging (MRI) can be a useful adjunct study in appropriate patients. In this report, we present a case in which MRI was used to diagnose traumatic avulsion and devascularization of the entire pancreas in a patient following a motor vehicle accident and we also include a review of the literature on this topic. It is our conclusion from this case report that MRI is the most effective imaging modality—specifically the subtraction post processing sequences—to evaluate severe pancreatic injury.

Therapeutic Serendipity Secondary to Abdominal Drain in Pancreatic Trauma

A case of blunt pancreatic trauma during a soccer match is presented in a young adult female. Following diagnosis, a laparotomy was performed and multiple abdominal drains placed. A controlled pancreatic fistula occurred, which was treated conservatively. Spontaneous drain migration into the duodenum created a therapeutic iatrogenic internal fistula.

Clinical update on management of pancreatic trauma

BACKGROUND

Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma.

METHODS

Systematic literature review until May 2018.

RESULTS

Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries.

CONCLUSION

Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.

Comparison of diagnostic imaging modalities for the evaluation of pancreatic duct injury in children: a multi-institutional analysis from the Pancreatic Trauma Study Group

PURPOSE

Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries.

METHODS

Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar's tests.

RESULTS

Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%, p < 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%, p = 0.28).

CONCLUSIONS

In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection.

LEVEL OF EVIDENCE

III.

Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades?

PURPOSE

Blunt trauma of pancreas in children is uncommon and its management varies from observational to early operative intervention. We analysed the feasibility and outcome of non-operative management in all grades of paediatric pancreatic injuries.

METHODS

A total of 15 patients of pancreatic trauma seen in a Paediatric Surgery Unit were retrospectively analyzed.

RESULTS

Age of the patients ranged from 3-11 years (mean, 7.7 years). The mode of injury was local trauma in 9 children. Only 3 patients had associated injuries and all were haemodynamically stable. Serum amylase levels were raised in 12 patients at admission which ranged from 400-1,000 IU. Computed tomography scan made a correct diagnosis in 14 patients. Grades of the injury varied from grade I-V (1, 3, 6, 4, 1 patients respectively). Fourteen patients were managed conservatively. One patient underwent laparotomy for suspected superior mesenteric hematoma. The average duration of enteral feeds was 3.7 days and of hospital stay was 9.4 days. Six patients formed pancreatic pseudocysts; two were managed conservatively while the other four underwent cystogastrostomy. The patients were followed up for a period of 1-12 years. All remained asymptomatic and none had exocrine or endocrine deficiencies.

CONCLUSION

Non-operative treatment for isolated blunt trauma of pancreas in children may be safely followed for all the grades of injury; if associated injuries requiring surgical intervention are ruled out with a good quality imaging and the patients are hemodynamically stable. It did not increase the hospital stay and morbidity and avoided operative intervention on acutely injured pancreas.

A traumatic pancreatic transection despite a child safety seat

A 5-year-old boy sustained blunt abdominal trauma in a car crash. The buckle mechanism of the five-point harness of his child safety seat compressed his upper abdomen causing an isolated complete pancreatic rupture. Diagnosis was delayed due to subtle symptoms and normal initial findings. A CT scan confirmed diagnosis. An emergency limited central pancreatic resection was performed. The outcome was excellent.

Predicting pseudocyst formation following pancreatic trauma in pediatric patients

BACKGROUND

There are insufficient data on pre-screening for pancreatic pseudocysts (PC) following pancreatic trauma. This study investigated the use of radiological and laboratory testing for predicting the development of pancreatic pseudocysts after trauma.

MATERIALS AND METHODS

The clinical records of all pediatric patients presenting with pancreatic trauma between January 2003 and December 2014 were reviewed retrospectively. Patients with American Association for the Surgery of Trauma (AAST) scores of Grade 3-5 were enrolled. The patients were divided into groups that developed [Group 1 (n = 20)] and did not develop [Group 2 (n = 18)] PC. The patients were evaluated in terms of their baseline characteristics, additional injuries, Injury Severity Score (ISS), pancreatic injury site, blood amylase levels 2 h and 10-15 days after the trauma, clinical presentation, and duration of intensive care unit (ICU) stay.

FINDINGS

We followed 38 patients. Of the patients in Group 1, 70 % had an injury to the tail of the pancreas. The ISS trauma scores and durations of hospitalization and ICU stay were significantly greater in Group 2 (p < 0.05). The mean blood amylase level on Day 1 was 607 U/L (range 183-801 U/L) in Group 1 and 314 U/L (range 25-631 U/L) in Group 2; the respective levels on Day 10 were 838 U/L (range 123-2951 U/L) and 83.2 U/L (range 35-164 U/L). The serum amylase levels were significantly higher (p < 0.001) in Group 1 than in Group 2 on Days 1 and 10. Four patients developed complications and two patients died.

CONCLUSION

Pancreatic pseudocyst formation is more likely in patients with AAST Grade 3 pancreatic injury, also serum amylase levels ten times greater than normal 2 h after the trauma, and persistently elevated serum amylase levels 10-15 days following the trauma.

Blunt pancreatic trauma: A persistent diagnostic conundrum?

Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality. In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Early detection of pancreatic trauma is essential to prevent subsequent complications. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma.

Management of pancreatic trauma: A pancreatic surgeon's point of view

BACKGROUND

Pancreatic trauma occurs in 0.2% of patients with blunt trauma and 1-12% of patients with penetrating trauma. Traumatic pancreatic injuries are characterised by high morbidity and mortality, which further increase with delayed diagnoses. The diagnosis of pancreatic trauma is challenging. Signs and symptoms can be non-specific or even absent.

METHODS

A critical review of studies reporting the management and outcomes of pancreatic trauma was performed.

RESULTS

The management of pancreatic trauma depends on the haemodynamic stability of the patient, the degree and location of parenchymal injury, the integrity of the main pancreatic duct, and the associated injuries to other organs. Nevertheless, the involvement of the main pancreatic duct is the most important predictive factor of the outcome. The majority of pancreatic traumas are managed by medical treatment (parenteral nutrition, antibiotic therapy and somatostatin analogues), haemostasis, debridement of devitalised tissue and closed external drainage. If a proximal duct injury is diagnosed, endoscopic transpapillary stent insertion can be a viable option, while surgical resection by pancreaticoduodenectomy is restricted to an extremely small number of selected cases. Injuries of the distal parenchyma or distal duct may be managed with distal pancreatectomy with spleen preservation. At the pancreatic neck, when pancreatic transection occurs without damage to the parenchyma, a parenchyma-sparing procedure is feasible.

CONCLUSION

The management of pancreatic injuries is complex and often requires a multidisciplinary approach. Here, we propose a management algorithm that is based on parenchymal damage and the site of duct injury.

Pancreatic trauma: The role of computed tomography for guiding therapeutic approach

AIM: To evaluate the role of computed tomography (CT) for diagnosing traumatic injuries of the pancreas and guiding the therapeutic approach.

METHODS: CT exams of 6740 patients admitted to our Emergency Department between May 2005 and January 2013 for abdominal trauma were retrospectively evaluated. Patients were identified through a search of our electronic archive system by using such terms as “pancreatic injury”, “pancreatic contusion”, “pancreatic laceration”, “peri-pancreatic fluid”, “pancreatic active bleeding”. All CT examinations were performed before and after the intravenous injection of contrast material using a 16-slice multidetector row computed tomography scanner. The data sets were retrospectively analyzed by two radiologists in consensus searching for specific signs of pancreatic injury (parenchymal fracture and laceration, focal or diffuse pancreatic enlargement/edema, pancreatic hematoma, active bleeding, fluid between splenic vein and pancreas) and non-specific signs (inflammatory changes in peri-pancreatic fat and mesentery, fluid surrounding the superior mesenteric artery, thickening of the left anterior renal fascia, pancreatic ductal dilatation, acute pseudocyst formation/peri-pancreatic fluid collection, fluid in the anterior and posterior pararenal spaces, fluid in transverse mesocolon and lesser sac, hemorrhage into peri-pancreatic fat, mesocolon and mesentery, extraperitoneal fluid, intra-peritoneal fluid).

RESULTS: One hundred and thirty-six/Six thousand seven hundred and forty (2%) patients showed CT signs of pancreatic trauma. Eight/one hundred and thirty-six (6%) patients underwent surgical treatment and the pancreatic injures were confirmed in all cases. Only in 6/8 patients treated with surgical approach, pancreatic duct damage was suggested in the radiological reports and surgically confirmed in all cases. In 128/136 (94%) patients who underwent non-operative treatment CT images showed pancreatic edema in 97 patients, hematoma in 31 patients, fluid between splenic vein and pancreas in 113 patients. Non-specific CT signs of pancreatic injuries were represented by peri-pancreatic fat stranding and mesentery fluid in 89% of cases, thickening of the left anterior renal fascia in 65%, pancreatic ductal dilatation in 18%, acute pseudocyst/peri-pancreatic fluid collection in 57%, fluid in the pararenal spaces in 45%, fluid in transverse mesocolon and lesser sac in 29%, hemorrhage into peri-pancreatic fat, mesocolon and mesentery in 66%, extraperitoneal fluid in 66%, intra-peritoneal fluid in 41% cases.

CONCLUSION: CT represents an accurate tool for diagnosing pancreatic trauma, provides useful information to plan therapeutic approach with a detection rate of 75% for recognizing ductal lesions.

Imaging of Pancreatic and Duodenal Trauma

Pancreatic and duodenal injuries are rare but life-threatening occurrences, often occurring in association with other solid organ injuries. Findings of pancreatic and duodenal trauma on computed tomography and MR imaging are often nonspecific, and high levels of clinical suspicion and understanding of mechanism of injury are imperative. Familiarity with the grading schemes of pancreatic and duodenal injury is important because they help in assessing for key imaging findings that directly influence management. This article presents an overview of imaging of blunt and penetrating pancreatic and duodenal injuries, including pathophysiology, available imaging techniques, and variety of imaging features.

Evaluation of diagnostic utility of multidetector computed tomography and magnetic resonance imaging in blunt pancreatic trauma: a prospective study

BACKGROUND

Blunt pancreatic trauma is an uncommon injury with high morbidity and mortality. Retrospective analyses of computed tomography (CT) performance report CT to have variable sensitivity in diagnosing pancreatic injury. Both a prospective analysis of multidetector CT (MDCT) performance and diagnostic utility of magnetic resonance imaging (MRI) in acute blunt pancreatic injury remain unexplored.

PURPOSE

To prospectively evaluate the utility of MDCT with MRI correlation in patients with blunt pancreatic trauma using intraoperative findings as the gold standard for analysis.

MATERIAL AND METHODS

The contrast-enhanced CT (CECT) scans of patients admitted with blunt abdominal trauma were prospectively evaluated for CT signs of pancreatic injury. Patients detected to have pancreatic injury on CT were assigned a CT grade of injury according to American Association for Surgery of Trauma classification. MRI was performed in patients not undergoing immediate laparotomy and MRI grade independent of CT grade was assigned. Surgical grade was taken as gold standard and accuracy of CT and MRI for grading pancreatic injury and pancreatic ductal injury (PDI) was calculated. A quantitative and qualitative comparison of MRI was also done with CT to determine the performance of MRI in acute pancreatic injury.

RESULTS

Thirty out of 1198 patients with blunt trauma abdomen were detected to have pancreatic injury on CT, which was surgically confirmed in 24 patients. Seventeen underwent MRI and surgical correlation was available in 14 patients. CT and MRI correctly identified the grade of pancreatic injury in 91.7% (22/24) and 92.86% (13/14) patients, respectively. Both CT and MRI correctly identified PDI in 18/19 and 11/12 patients, respectively, with good inter-modality agreement of 88.9% (kappa value of 0.78). MRI also qualitatively added to the information provided by CT and increased diagnostic confidence in 58.8% of patients.

CONCLUSION

MDCT performs well in grading pancreatic injury and evaluating pancreatic ductal injury. MRI is useful in evaluation of acute pancreatic trauma as it can increase diagnostic confidence and provide more qualitative information regarding the extent of injury.

BWH emergency radiology-surgical correlation: pancreatic laceration

We describe the radiological and intraoperative correlation of pancreatic laceration in a 76-year-old unrestrained motor-vehicle driver following blunt abdominal trauma. The purpose of this article is to emphasize the importance of recognizing pancreatic injuries in trauma patients, as these injuries are rare and can be overlooked on CT.

Intra-abdominal Solid Organ Injuries: An Enhanced Management Algorithm

The organ injury scale grading system proposed by the American Association for the Surgery of Trauma provides guidelines for operative versus nonoperative management in solid organ injuries; however, major shortcomings of the American Association for the Surgery of Trauma injury scale may become apparent with low-grade injuries, in which conservative management may fail. Nonoperative management of common intra-abdominal solid organ injuries relies increasingly on computed tomographic findings and other clinical factors, including patient age, presence of concurrent injuries, and serial clinical assessments. Familiarity with characteristic imaging features is essential for the prompt diagnosis and appropriate treatment of blunt abdominal trauma. In this pictorial essay, the spectrum of the American Association for the Surgery of Trauma organ injury scale grading system is illustrated, and a multidisciplinary management algorithm for common intra-abdominal solid organ injuries is proposed.

Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review

INTRODUCTION

Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date.

METHODS

A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations.

RESULTS

33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h.

CONCLUSIONS

Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.

Diagnosis and treatment of traumatic pancreatic injuries

Pancreatic trauma accounted for 1%-5% of all blunt abdominal injuries and 12% of penetrating abdominal injuries. Although pancreatic trauma is uncommon, its mortality is high. Early accurate diagnosis, selection of suitable means of treatment based on the degree of injury, and management of complications are issues that should be stressed in the treatment of pancreatic trauma. This article discusses the clinical diagnosis, treatment and complications of pancreatic trauma.

Evaluation of blunt pancreatic injury with contrast-enhanced ultrasonography in comparison with contrast-enhanced computed tomography

The aim of the present study was to evaluate acute blunt pancreatic injury using contrast-enhanced ultrasonography (CEUS) in comparison with contrast-enhanced computed tomography (CECT). Superficial and deep lesions were established by blunt pancreatic injury in 40 Chinese Guangxi Bama miniature pigs. Conventional ultrasound (US), CEUS and CECT were performed to detect traumatic lesions in the pancreas. A total of 40 lesions were established, including 20 deep lesions and 20 superficial lesions. US identified 21 of the 40 lesions, including 7 of the 20 superficial and 14 of the 20 deep lesions. CEUS identified 34 of the 40 lesions, including 14 of the 20 superficial and 20 of the 20 deep lesions. CECT identified 33 of the 40 lesions, including 13 of the 20 superficial and 20 of the 20 deep lesions. The detection rate of acute blunt pancreatic injury using CEUS was significantly higher compared with that using US (85 vs. 52.5%, P<0.05), however there was no significant difference in the detection rate of pancreatic lesions between CEUS and CECT (85 vs. 82.5%, P>0.05). CEUS improves the diagnostic levels of conventional US and is comparable with CECT scans in the diagnosis of blunt pancreatic injury.

Blunt polytrauma: evaluation with 64-section whole-body CT angiography

Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.

Evolving management of pancreatic injury

PURPOSE OF REVIEW

In this study we present a concise review of the evolving management of traumatic injury to the pancreas, including diagnostic approaches and options for operative and nonoperative intervention.

RECENT FINDINGS

New diagnostic adjuncts can be used for the evaluation of injury to the pancreas and pancreatic duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) are used as diagnostic modalities for duct evaluation. ERCP can be therapeutic with sphincterotomy and/or stenting for duct disruption. Computed tomography scan is the initial imaging study of choice for pancreatic injury, but is also used for drainage of pancreatic abscesses or pseudocysts.

SUMMARY

Nonoperative management of solid organ injuries is the recommended treatment in hemodynamically stable patients. This strategy is now being successfully applied to pancreatic injuries in specific situations. However, the mainstays of pancreatic injury remain the same. The identification of pancreatic duct injury is the top priority. Management includes distal resection, debridement, and closed suction drainage of pancreatic injuries.

Trauma and the endocrine system

The endocrine system may be the target of different types of trauma with varied consequences. The present article discusses trauma of the hypothalamic-pituitary axes, adrenal glands, gonads, and pancreas. In addition to changes in circulating hormone levels due to direct injury to these structures, there may be an endocrine response in the context of the stress caused by the trauma.