CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation

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.

Curiosity or Underdiagnosed? Injuries to Thoracolumbar Spine with Concomitant Trauma to Pancreas

The pancreas is at risk of damage as a consequence of thoracolumbar spine injury. However, there are no studies providing prevalence data to support this assumption. Data from European hospitals documented in the TraumaRegister DGU^® (TR-DGU) between 2008–2017 were analyzed to estimate the prevalence of this correlation and to determine the impact on clinical outcome. A total of 44,279 patients with significant thoracolumbar trauma, defined on Abbreviated Injury Scale (AIS) as ≥2, were included. Patients transferred to another hospital within 48 h were excluded to prevent double counting. A total of 135,567 patients without thoracolumbar injuries (AIS ≤ 1) were used as control group. Four-hundred patients with thoracolumbar trauma had a pancreatic injury. Pancreatic injuries were more common after thoracolumbar trauma (0.90% versus (vs.) 0.51%, odds ratio (OR) 1.78; 95% confidence intervals (CI), 1.57–2.01). Patients with pancreatic injuries were more likely to be male (68%) and had a higher mean Injury Severity Score (ISS) than those without (35.7 ± 16.0 vs. 23.8 ± 12.4). Mean length of stay (LOS) in intensive care unit (ICU) and hospital was longer with pancreatic injury. In-hospital mortality was 17.5% with and 9.7% without pancreatic injury, respectively. Although uncommon, concurrent pancreatic injury in the setting of thoracolumbar trauma can portend a much more serious injury.

Pancreatic Trauma: Imaging Review and Management Update

Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ^©RSNA, 2020 See discussion on this article by Patlas.

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.

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.

Pancreaticobiliary Trauma: A Multimodality Imaging Update

Pancreaticobiliary injury is an uncommon entity which more often occurs in the setting of blunt than penetrating trauma. We present cases of pancreaticobiliary traumatic injuries from our Level 1 trauma center to illustrate an imaging update on the spectrum of injuries and correlation with current grading systems.

Emergency CT of blunt abdominal trauma: experience from a large urban hospital in Southern China

Trauma is one of the leading causes of death for men and women under the age of 45 years old, and abdominal injuries contribute to a large number of these deaths. Prompt diagnosis is very important for treatment decision making and can be life-saving. CT has become an essential imaging modality in emergency medicine. In this pictorial review, we present our experience of CT in blunt abdominal trauma and describe CT findings of common injuries, including hemoperitoneum, solid viscera, hollow viscera, mesenteric and diaphragmatic injuries. Unenhanced CT is routinely used, tailored protocols should be reserved for patients with questionable or subtle findings at unenhanced CT, especially for bowel and mesenteric injuries. The decision can be made by radiologists based on initial findings or by referring clinicians based by clinical presentations or deterioration of patients' condition.

Trends in nonoperative management of traumatic injuries - A synopsis

Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or "conservative" management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon's disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed.

REPUBLISHED WITH PERMISSION FROM

Stawicki SPA. Trends in nonoperative management of traumatic injuries - A synopsis. OPUS 12 Scientist 2007;1(1):19-35.

Magnitude, Severity, and Outcome of Traumatic Pancreatic Injury at a Level I Trauma Center in India

Pancreatic injury is an uncommon and frequently missed injury in abdominal trauma patients. However, missed pancreatic injury is associated with significant morbidity and mortality. This study was conducted to know the burden of pancreatic injury and its outcome in our setup. A retrospective analysis of 53 patients with pancreatic injury from January 2008 through March 2012 at the Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi. Pancreatic injuries were present in 1.18 % of all trauma admissions. Blunt trauma to the abdomen (n = 49, 92.45 %) due to road traffic injury (n = 38, 71.70 %) was the most common mechanism of injury. Isolated pancreatic injury was present in eight (15.09 %) patients. Grade III pancreatic injury (n = 25, 47 %) was the most common. Of these patients, 18.86 % were managed nonoperatively and 81.13 % were managed operatively. Among the operatively managed patients (n = 43), 74.4 % were operated due to pancreatic injury and 25.5 % were operated due to associated injuries. Distal pancreatectomy with or without spleen preservation (n = 25) was the most common operative procedure done. Three out of five patients of Whipple operation for pancreatic injury died. Pancreatic injury was associated with complications in 43.40 % and death in 20 % (n = 11). Pancreatic injury is rare, but delay in diagnosis of pancreatic injury has been associated with higher morbidity and mortality. Low-grade pancreatic injury with intact main pancreatic duct (MPD) could be successfully managed nonoperatively, whereas in high-grade pancreatic injury, an operative intervention is invariably necessary. Distal pancreatectomy with spleen preservation is a desirable goal whenever possible for distal transaction of the pancreas. Whipple resection should be reserved only for hemodynamically stable patients with complex pancreaticoduodenal injury and is associated with high mortality.

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.

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.

[Abdominal polytrauma and parenchymal organs]

CLINICAL/METHODOLOGICAL ISSUE

The acute radiological diagnostics of polytrauma patients has become an essential part of the interdisciplinary treatment in the emergency room. The incidence of polytrauma patients with an injury severity score (ISS) >16 is approximately 450 cases/million inhabitants/year in Europe. Injuries of the parenchymal organs are of utmost importance for the prognosis and treatment of these patients. The injury patterns are complex and a great deal of experience is necessary to be able to obtain the correct diagnosis within minutes. This review article deals with the radiological diagnostics and grading of the severity of injuries to the spleen, liver, pancreas and kidneys.

STANDARD RADIOLOGICAL METHODS

The use of ultrasound for the evaluation of polytraumatized patients will be discussed. The most important trauma-associated findings for the above mentioned organs using multidetector computed tomography (MDCT) will be described and illustrated by dedicated case findings.

METHODOLOGICAL INNOVATIONS

Ultrasound contrast agents can supply valuable, additional diagnostic information in the evaluation of polytraumatized patients. Computed tomography has become established as the most relevant imaging modality in severe trauma. Innovative organ-adapted and contrast application protocols improve the diagnostic performance of MDCT.

PRACTICAL RECOMMENDATIONS

The use of focused assessment sonography for trauma (FAST) scanning as a screening tool is in agreement with the other clinical disciplines of the trauma team. The use of MDCT is trauma-dependent and the classification of the severity of the different parenchymal organ injuries is ultimately decisive for further treatment and prognosis of trauma victims.

Blunt abdominal trauma: imaging and intervention

Interventional radiology, particularly percutaneous angioembolization, plays an important role in the management of blunt abdominal trauma involving solid organs and pelvic fractures. The traumatic injuries of the central nervous system, heart, and great vessels often lead to death at the site of trauma. Although patients with visceral organ injuries can also die at the site of trauma, these patients often reach the hospital thus giving us an opportunity to treat them with surgical or radiological intervention depending on the clinical condition of the patient. The management of these patients with trauma is now well codified-patients who remain unstable despite resuscitation should be shifted either to an operating room for laparotomy if the ultrasound (US) revealed hemoperitoneum or to a interventional room for angioembolization in cases of pelvic fractures. In all other cases, computed tomography is essential. Currently, multidetector computed tomography with contrast is the gold standard imaging modality for the diagnosis of traumatic abdominal injuries; it helps in assessing the extent of injuries, and further management can be planned.

Emergency contrast-enhanced ultrasonography for pancreatic injuries in blunt abdominal trauma

PURPOSE

The purpose of this study was to retrospectively investigate the application of emergency contrast-enhanced ultrasonography (CEUS) in blunt pancreatic trauma.

MATERIALS AND METHODS

Twenty-two consecutive patients with blunt pancreatic trauma were examined using CEUS from March 2007 to June 2012. The findings of CEUS were compared with those of contrast-enhanced computed tomography scans at level-1 diagnostic tests.

RESULTS

Out of the 22 patients, 21 were diagnosed with blunt pancreatic injury using CEUS, including 8 patients with lesions in the neck of pancreas, 9 in the body, 3 in the tail and 1 in the head. The injury sites appeared as anechoic and/or hypoechoic perfusion defect regions with irregular borders in parenchyma and capsule on CEUS images. The lesion sizes measured by CEUS were 1.88 ± 0.81 cm, which were consistent with the 1.93 ± 0.77 cm measured by CT (p > 0.05). Using CT as a reference standard, the detection rate of CEUS in blunt pancreatic trauma was 95.5 % (21/22).

CONCLUSIONS

CEUS findings can be used to provide a reliable diagnosis for blunt pancreatic trauma. CEUS is thus promising in the assessment of blunt pancreatic trauma, especially in institutions where emergency CEUS is used as an initial diagnostic instrument.

Pancreatic trauma: A concise review

Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities, and these injuries are often overlooked in cases with extensive multiorgan trauma. The most evident findings of pancreatic injury are post-traumatic pancreatitis with blood, edema, and soft tissue infiltration of the anterior pararenal space. The alterations of post-traumatic pancreatitis may not be visualized within several hours following trauma as they are time dependent. Delayed diagnoses of traumatic pancreatic injuries are associated with high morbidity and mortality. Imaging plays an important role in diagnosis of pancreatic injuries because early recognition of the disruption of the main pancreatic duct is important. We reviewed our experience with the use of various imaging modalities for diagnosis of blunt pancreatic trauma.

Pancreatic trauma

INTRODUCTION

Pancreatic trauma occurs in approximately 4% of all patients sustaining abdominal injuries. The pancreas has an intimate relationship with the major upper abdominal vessels, and there is significant morbidity and mortality associated with severe pancreatic injury. Immediate resuscitation and investigations are essential to delineate the nature of the injury, and to plan further management. If main pancreatic duct injuries are identified, specialised input from a tertiary hepatopancreaticobiliary (HPB) team is advised.

METHODS

A comprehensive online literature search was performed using PubMed. Relevant articles from international journals were selected. The search terms used were: 'pancreatic trauma', 'pancreatic duct injury', 'radiology AND pancreas injury', 'diagnosis of pancreatic trauma', and 'management AND surgery'. Articles that were not published in English were excluded. All articles used were selected on relevance to this review and read by both authors.

RESULTS

Pancreatic trauma is rare and associated with injury to other upper abdominal viscera. Patients present with non-specific abdominal findings and serum amylase is of little use in diagnosis. Computed tomography is effective in diagnosing pancreatic injury but not duct disruption, which is most easily seen on endoscopic retrograde cholangiopancreaticography or operative pancreatography. If pancreatic injury is suspected, inspection of the entire pancreas and duodenum is required to ensure full evaluation at laparotomy. The operative management of pancreatic injury depends on the grade of injury found at laparotomy. The most important prognostic factor is main duct disruption and, if found, reconstructive options should be determined by an experienced HPB surgeon.

CONCLUSIONS

The diagnosis of pancreatic trauma requires a high index of suspicion and detailed imaging studies. Grading pancreatic injury is important to guide operative management. The most important prognostic factor is pancreatic duct disruption and in these cases, experienced HPB surgeons should be involved. Complications following pancreatic trauma are common and the majority can be managed without further surgery.

Blunt pancreatic trauma: evaluation with MDCT technology

The purpose of this paper is to determine the relative frequency of multi-detector CT (MDCT) findings of pancreatic injury in blunt trauma and to determine their diagnostic accuracy in predicting main pancreatic duct injury. Fifty-three patients (31 male, 22 female; mean 44.1 years) with blunt trauma and admission MDCT findings suspicious for pancreatic injury or who underwent MDCT and had a discharge diagnosis of pancreatic trauma were included in this study. Two radiologists reviewed all images and recorded findings suspicious for pancreatic injury, which were subsequently compared to surgical findings to generate diagnostic accuracy. MDCT imaging findings suggestive of pancreatic injury included low attenuation peripancreatic fluid (n = 51), hyperattenuating peripancreatic fluid (n = 13), pancreatic contusion (n = 7), active hemorrhage (n = 2), and pancreatic laceration (n = 16). Diagnostic accuracy of the various imaging findings varied for diagnosing main duct injury; there were highly sensitive, nonspecific imaging findings such as the presence of low attenuation peripancreatic fluid (sensitivity, 100 %; specificity 4.9 %) as well as insensitive, specific findings such as visualizing a pancreatic laceration involving >50 % of the parenchymal width (sensitivity, 50 %; specificity, 95.1 %). In the setting of blunt abdominal trauma, MDCT imaging findings can be grouped into two categories for determining integrity of the main pancreatic duct: indirect, highly sensitive but nonspecific findings and direct, specific but insensitive findings. Awareness of the clinical implications of the various MDCT imaging findings of pancreatic trauma is useful in interpreting their significance.

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.

Multidetector CT of blunt abdominal trauma

The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention.

Computed tomography for pancreatic injuries in pediatric blunt abdominal trauma

AIM: To evaluate the efficacy of computed tomography scan in diagnosing and grading the pattern of pancreatic injuries in children.

METHODS: We conducted a retrospective study to review medical files of children admitted with blunt pancreatic injuries to the Maternity and Children Hospital Al-Madina Al-Munawwarah, Kingdom of Saudi Arabia. The demographic details and mechanisms of injury were recorded. From the database of the Picture Archiving and Communication System of the radiology department, multidetector computed tomography (MDCT) images of the pancreatic injuries, severity, type of injuries and grading of pancreatic injuries were established.

RESULTS: Seven patients were recruited in this study over a period of 5 years; 5 males and 2 females with a mean age of 7 years (age range 5-12 years). Fall from height was the most frequent mechanism of injury, reported in 5 (71%), followed by road traffic accident (1 patient, 14%) and cycle handlebar (1 patient, 14%) injuries. According to the American Association for the Surgery of Trauma grading system, 1 (14%) patient sustained Grade I, 1 (14%) Grade II, 3 (42%) Grade III and 2 (28%) patients were found to have Grade V pancreatic injuries. This indicated a higher incidence of severe pancreatic injuries; 5 (71.4%) patients were reported to have Grade III and higher on the injury scale. Three (42%) patients had associated abdominal organ injuries.

CONCLUSION: Pediatric pancreatic injuries due to blunt abdominal trauma are rare. The majority of the patients sustained extensive pancreatic injuries. MDCT findings are helpful and reliable in diagnosing and grading the pancreatic injuries.

Imaging of miscellaneous pancreatic pathology (trauma, transplant, infections, and deposition)

In this article's coverage of miscellaneous pancreatic topics, a brief review of pancreatic trauma; pancreatic transplantation; rare infections, such as tuberculosis; deposition disorders, including fatty replacement and hemochromatosis; cystic fibrosis; and others are discussed with pertinent case examples.

The efficacy of four-slice helical CT in evaluating pancreatic trauma: a single institution experience

STUDY OBJECTIVE

To assess the efficacy of computed tomography (CT) in evaluating patients with pancreatic trauma.

METHODS

We undertook a retrospective review of all blunt trauma patients admitted to the Chi-Mei Medical Center from January 2004 to June 2006. Every patients underwent abdominal CT scan in emergency department and the CT scans were obtained with a four-slice helical CT. Diagnosis of a pancreatic injury in these patients was by surgical observation or by CT findings. Radiographic pancreatic injuries were classified as deep or superficial lesions. Deep lesions were defined as the hematomas or lacerations >50% thickness of the pancreas. Superficial lesions were described as the hematomas or lacerations <50% thickness of the pancreas; pancreatic edema; and focal fluid accumulation around the pancreas

RESULTS

Nineteen patients with pancreatic trauma, fourteen males and five females, average age 40.6 ± 21.4 years, were included. Most patients (73.7%) with pancreatic trauma had associated organ injuries. CT was performed in all patients and laparotomy in 14 patients. CT was 78.9% sensitive in detecting pancreatic trauma. All deep pancreatic lesions revealed on CT required surgical treatment, and complication was discovered in two patients undergoing delayed surgery. Superficial lesions were managed conservatively.

CONCLUSION

Four-slice helical CT can detect most pancreatic trauma and provide practical therapeutic guidance. Delayed operation might result in complications and is associated with prolonged hospital stays.

MR imaging for blunt pancreatic injury

OBJECTIVE

To study the MR imaging features of blunt pancreatic injury.

MATERIALS AND METHODS

Nine patients with pancreatic injury related to blunt abdominal trauma confirmed by surgery performed MR imaging. Two abdominal radiologists conducted a review of the MR images to assess pancreatic parenchymal and pancreatic duct injury, and associated complications.

RESULT

Diagnostic quality MR images were obtained in each of the nine patients. In the nine patients, pancreatic fracture, laceration and contusion were depicted on MR imaging in five, one and three patients, respectively. There were six patients with pancreatic duct disruption, eight patients with peripancreatic fluid collections, and four patients with peripancreatic pseudocyst or hematoma, respectively. All of the MR imaging findings was corresponded to surgical findings.

CONCLUSION

MR imaging is an effective method to detect blunt pancreatic injury and may provide information to guide management decisions.

Imaging of blunt pancreatic trauma

Blunt pancreatic trauma is an exceedingly rare but life-threatening injury with significant mortality. Computed tomography (CT) is commonly employed as the initial imaging modality in blunt trauma patients and affords a timely diagnosis of pancreatic trauma. The CT findings of pancreatic trauma can be broadly categorized as direct signs, such as a pancreatic laceration, which tend to be specific but lack sensitivity and indirect signs, such as peripancreatic fluid, which tend to be sensitive but lack specificity. In patients with equivocal CT findings or ongoing clinical suspicion of pancreatic trauma, magnetic resonance cholangiopancreatography (MRCP) may be employed for further evaluation. The integrity of the main pancreatic duct is of crucial importance, and though injury of the duct may be strongly suggested upon initial CT, MRCP provides clear delineation of the duct and any potential injuries. This article aims to review and illustrate the CT and magnetic resonance imaging findings of blunt pancreatic trauma and delineate the integration of these modalities into the appropriate imaging triage of severely injured blunt trauma patients.

Management of blunt pancreatic trauma in children

PURPOSE

Blunt abdominal trauma is the major cause of abdominal injury in children. Because of the retroperitoneal location, insidious signs and symptoms and the lack of sensitivity with common imaging modalities often lead to difficulties in making an accurate diagnosis. The most common complication is the formation of a pancreatic fistula, pancreatitis and a pancreatic pseudocyst, which usually manifests within 3 or 4 weeks after injury.

METHODS

The case records of seven children (4 male, 3 female) treated for blunt pancreatic injury in the department of pediatric surgery, University Hospital, Split were reviewed.

RESULTS

The treatment modalities were selected according to the grade of the pancreatic injury, hemodynamic status and associated injuries. Because all of the patients were classified as grade I or II according to the American Association for the Surgery of Trauma (AAST) classification, a conservative treatment was selected for all seven patients. In four patients the conservative treatment resulted in the total regression of the clinical, biochemical and radiological signs within four weeks (AAST grade I). In the other three patients, pancreatic pseudocysts arose within 3 or 4 weeks after the injury (AAST grade II).

CONCLUSIONS

The status of the main pancreatic duct and the location of the pancreatic injury constitute the basis of the AAST scoring system. This scale should be used as a guide to selecting a surgical or conservative strategy. Based on these data, two factors appear to be the most important determinants of the treatment strategy for children with pancreatic injury: the grade of the pancreatic injury, which is determined according to the status of the main pancreatic duct and the clinical status of the patient.

Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings

Multidetector computed tomography (CT) represents a significant advance in CT technology and can allow the accurate assessment of trauma patients, including the detection of traumatic retroperitoneal injuries, many of which are clinically occult. Retroperitoneal injuries include duodenal, pancreatic, vascular, renal, and adrenal injuries. Abnormal blood, fluid, or air within the retroperitoneal spaces may be isolated findings but can also occur in association with these injuries, and their recognition is the key to correctly identifying the injury. Accurate characterization of injury with CT can affect clinical management and can help minimize unnecessary laparotomies. Equivocal findings at initial abdominal CT should prompt close clinical follow-up with possible imaging follow-up, particularly for suspected occult duodenal and pancreatic injuries.

Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology

Pancreatic and duodenal injuries after blunt abdominal trauma are rare; however, delays in diagnosis and treatment can significantly increase morbidity and mortality. Multidetector computed tomography (CT) has a major role in early diagnosis of pancreatic and duodenal injuries. Detecting the often subtle signs of injury with whole-body CT can be difficult because this technique usually does not include a dedicated protocol for scanning the pancreas. Specific injury patterns in the pancreas and duodenum often have variable expression at early posttraumatic multidetector CT: They may be hardly visible, or there may be considerable exudate, hematomas, organ ruptures, or active bleeding. An accurate multidetector CT technique allows optimized detection of subtle abnormalities. In duodenal injuries, differentiation between a contusion of the duodenal wall or mural hematoma and a duodenal perforation is vital. In pancreatic injuries, determination of involvement of the pancreatic duct is essential. The latter conditions require immediate surgical intervention. Use of organ injury scales and a surgical classification adapted for multidetector CT enables classification of organ injuries for trauma scoring, treatment planning, and outcome control. In addition, multidetector CT reliably demonstrates potential complications of duodenal and pancreatic injuries, such as posttraumatic pancreatitis, pseudocysts, fistulas, exudates, and abscesses.

Multidetector-row computed tomography (CT) of blunt pancreatic injuries: can contrast-enhanced multiphasic CT detect pancreatic duct injuries?

BACKGROUND

We examined patients of blunt trauma with contrast-enhanced multiphasic computed tomography (CT) and determined if it could detect pancreatic duct injuries.

METHODS

During a 17-month period, 95 patients of blunt abdominal trauma underwent multiphasic CT examinations. The CT grading scales of pancreatic injuries at parenchymal phase, portal venous phase, and equilibrium phase were recorded and compared with surgery, endoscopic retrograde cholangiopancreatography, or discharged diagnosis. The diagnostic values of multiphasic CT and interobserver agreements at different phases were computed.

RESULTS

Of the 95 patients, nine (9.5%) had pancreatic injuries (six with main duct injuries, three without main duct injuries). The interobserver agreement presented in kappa values between two radiologists regarding the integrity or disruption of the main duct were good at parenchymal phase (K = 0.73), portal venous phase (K = 0.64), and equilibrium phase (K = 0.68). The overall accuracies of multiphasic CT in detecting main duct injuries were 97.9% (parenchymal phase), 100.0% (portal venous phase), and 96.8% (equilibrium phase), respectively. The sensitivity (50.0%) and negative predictive value (96.7%) of equilibrium phase CT were the lowest among the three phases of CT scans.

CONCLUSION

The portal venous phase CT was the most accurate scan to detect pancreatic duct injuries. However, equilibrium phase CT might underestimate major pancreatic injuries. Multiphasic CT shows early promise in this clinical application and further multi-institutional studies to verify its accuracy and reveal the optimal CT methodology are needed.

Pancreatic laceration and portal vein thrombosis in blunt trauma abdomen

Injuries to the pancreas by blunt trauma are uncommon. The association of pancreatic injury with acute portal vein thrombosis secondary to blunt trauma abdomen is furthermore rare. The early diagnosis of the pancreas with injury to the portal vein is challenging and difficult. These injuries are associated with high morbidity and mortality, particularly if the diagnosis is delayed. Accurate and early diagnosis is therefore imperative and computed tomography plays a key role in detection. We present a case of child with a rare combination of pancreatic laceration and acute portal vein thrombosis following a blunt trauma to the abdomen. With extensive literature search we found no such cases has been described previously.

CT of blunt pancreatic trauma: a pictorial essay

Blunt trauma to pancreas is uncommon and clinical features are often non-specific and unreliable leading to possible delays in diagnosis and therefore increased morbidity. CT has been established as the imaging modality of choice for the diagnosis of abdominal solid-organ injury in the blunt trauma patient. The introduction of multidetector-row CT allows for high resolution scans and multiplanar reformations that improve diagnosis. Detection of pancreatic injuries on CT requires knowledge of the subtle changes produced by pancreatic injury. The CT appearance of pancreatic injury ranges from a normal initial appearance of the pancreas to active pancreatic bleeding. Knowledge of CT signs of pancreatic trauma and a high index of suspicion is required in diagnosing pancreatic injury.

Multislice computed tomography in blunt abdominal trauma

Blunt abdominal trauma is a frequent finding in patients with multiple trauma, and is associated with significant morbidity and mortality. Multislice computed tomography (MSCT), allowing for multiplanar reconstructions and three-dimensional images, has become the imaging modality of choice for these patients. MSCT is indicated in all haemodynamically stable patients with suspected blunt abdominal trauma. A `focussed CT' algorithm, as recommended by the Advanced Trauma Life Support (ATLS®) program, may be useful for patients with isolated abdominal trauma who are conscious and cooperative. For unconscious patients with or without multiple trauma `unfocussed' whole-body MSCT algorithms should be used, as these lead to earlier as well as more accurate diagnosis. MSCT allows for rapid diagnosis of abdominal and retroperitoneal injuries and for grading of solid organ injuries. Active haemorrhage may be detected with accuracy similar to angiography. Even bowel, diaphragmatic and bladder injuries, where CT used to miss a significant number of injuries, can be diagnosed with high accuracy by the new generation of MSCT scanners.

Diagnosis of duct disruption and assessment of pancreatic leak with dynamic secretin-stimulated MR cholangiopancreatography

OBJECTIVE

The management of pancreatic duct disruption is complex and depends on several factors including the cause, morphology, and degree of disruption. ERCP can show duct disruption in as many as 75% of patients but is invasive and cannot detect disruption beyond an obstruction. We studied the role of secretin MR cholangiopancreatography in patients with suspected pancreatic duct disruption.

CONCLUSION

Secretin MR cholangiopancreatography is a safe, noninvasive test that can provide additional useful information about duct integrity and facilitate management.

Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis

Injuries of the pancreas, gallbladder, and bile ducts due to blunt trauma are relatively uncommon and difficult to detect but are associated with high morbidity and mortality, especially if diagnosis is delayed. Accurate and early diagnosis is imperative, and imaging plays a key role in detection. Knowledge of the mechanisms of injury, the types of injuries, and the roles of various imaging modalities is essential for prompt and accurate diagnosis. Early recognition of disruption of the main pancreatic duct is important because such disruption is the principal cause of delayed complications. Computed tomography (CT) can demonstrate pancreatic parenchymal injuries and complications such as abscess, fistula, pancreatitis, and pseudocyst. CT findings can also suggest disruption of the pancreatic duct; however, the ability of CT to indicate this finding depends on the degree of parenchymal injury. Magnetic resonance (MR) cholangiopancreatography allows direct imaging of the pancreatic duct and sites of disruption. Gallbladder injuries can be detected with CT, ultrasonography, hepatobiliary scintigraphy, or MR cholangiopancreatography. CT findings include a collapsed gallbladder, wall thickening, inhomogeneous mural enhancement, and pericholecystic fluid. Bile duct injuries can be suggested with CT, which may show ascites and associated liver injuries, and can be confirmed with hepatobiliary scintigraphy.

[MR imaging in the evaluation of blunt pancreatic trauma]

Pancreatic injuries caused by blunt trauma are unusual but associated with a high morbidity and a high mortality because of a delay in diagnosis. Clinical and laboratory findings are non-specific. Accurate grading of blunt pancreatic injury with identification of pancreatic duct disruption helps to define practical treatment guidelines. Computed tomography does not allow direct visualization of the pancreatic duct and may result in low accuracy for the detection of ductal injury. Endoscopic retrograde pancreatography is the "gold standard" but invasive (3-5% complication rate, mainly pancreatitis) and may not be possible in up to 30% of patients, or requested after surgery. Endoscopic retrograde pancreatography may be used as a therapeutic modality (stenting of the main pancreatic duct). Magnetic resonance cholangiopancreatography is non invasive and preliminary results are promising. Magnetic resonance cholangiopancreatography detects pseudocysts, has multiplanar capability and complemented with conventional MR imaging allows evaluation of the pancreatic parenchyma.

Multi-detector row CT imaging of blunt abdominal trauma

CT is the imaging modality of choice to evaluate hemodynamically stable patients suffering blunt abdominal trauma. During the past five years, single-slice helical CT has been replaced by multidetector row CT (MDCT). This development has revolutionized cross-sectional imaging for blunt trauma patients. Volumetric imaging with helical CT has been a major factor supporting the nonoperative management of solid organ injury. Trauma centers in the United States are replacing single-slice helical CT scanners with state-of-the-art MDCT in suites proximate to the patient receiving area and with facilities for monitoring and maintaining physiologic support. The ability to obtain high-resolution images with MDCT during optimal contrast enhancement at unparalleled speed helps detect the presence and define the extent of injuries, and crucially, to diagnose hemorrhage and vascular injuries. This article describes our current imaging protocol with MDCT-16 (i.e., 16 detector MDCT), the spectrum of diagnostic findings seen in blunt abdominal injury, and the role of MDCT in the characterization of hemorrhage and planning injury management.

Management of blunt major pancreatic injury

BACKGROUND

Major duct injury is the principal determinant of outcome for patients with pancreatic trauma, and there are a number of therapeutic choices available specific to the location of the insult. We report a series of blunt major pancreatic injury cases, with a review of the different procedures used and a discussion of the results.

METHODS

A total of 48 cases of blunt major pancreatic injury treated during a 10-year period at one trauma center were reviewed retrospectively. Diagnosis and assessment of injury severity were based on imaging studies and proved by surgical findings. Charts were reviewed to establish the mechanism of injury, surgical indications and imaging studies, management strategy, and outcome.

RESULTS

Of the 32 grade III patients, 19 underwent distal pancreatectomy with splenectomy, 8 had pancreatectomy with preservation of the spleen, and 2 received a pancreatic duct stent, with the remaining 3 individuals undergoing nonsurgical treatment, pancreaticojejunostomy, and drainage alone, respectively. The grade III complication rate was 60.6%. Of the 14 grade IV patients, 4 underwent drainage alone because of the severity of the associated injuries, 4 underwent pancreaticojejunostomy, 3 had distal pancreatectomy with splenectomy, and 1 underwent distal pancreatectomy. The two remaining patients received a pancreatic duct stent. The grade IV complication rate was 53.8%. The Whipple procedure was performed for two grade V patients; one died subsequently. For all 48 patients, intraabdominal abscess was the most common morbidity (n = 11) followed, in order of prevalence, by major duct stricture (n = 4), pancreatitis (n = 2), pseudocyst (n = 2), pancreatic fistula (n = 1), and biliary fistula (n = 1). All stented cases developed complications, with one dying and three experiencing major duct stricture.

CONCLUSION

The complication rate for our cases of blunt major pancreatic injury was high (62.2%), especially when treatment was delayed more than 24 hours; the same result was also noted for cases transferred from other institutions. Distal pancreatectomy with spleen preservation had a lower complication rate (22.2%) compared with other procedures and is suggested for grade III and grade IV injuries. Magnetic resonance pancreatography was unreliable early after injury but was effective in the chronic stage. Although pancreatic duct stenting can be used to treat posttraumatic pancreatic fistula and pseudocyst, the major duct stricture in the chronic stage of recovery and the risk of sepsis in the acute stage must be overcome.

The use of MRCP in the detection of pancreatic injuries after blunt trauma

From January 2000 to November 2001, five consecutive, hemodynamically stable trauma patients (age range 8-69 years, mean age 34 years) with parenchymal injuries were evaluated by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). One patient also underwent a MRCP-facilitated secretin test. MRI depicted pancreatic laceration in two patients, ductal disruption and a post-traumatic intraparenchymal pseudocyst in one, migrating pancreatic fluid collection in the mediastinal space with disruption in another, and main pancreatic duct rupture and dilatation in the patient evaluated with MRCP following secretin administration. MRI with MRCP is an effective noninvasive test for detecting and managing pancreatic injuries after blunt trauma. Secretin administration improves ductal visualization, particularly of nondilated ducts. Finally, MRI was useful in the follow-up studies of parenchymal damage and minor ductal injuries, providing high-quality images of the pancreatic duct and biliary tract.

The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury

BACKGROUND

The status of the main pancreatic duct (MPD) is the most important determinant of the morbidity and mortality associated with pancreatic trauma. Early diagnosis and optimal treatment are critical, especially when there is MPD injury.

METHODS

Twenty-three patients with pancreatic trauma were studied prospectively with respect to clinical and laboratory findings, CT, and endoscopic retrograde pancreatography (ERP). Treatment modalities and clinical outcome were assessed in relation to ERP findings.

RESULTS

The pancreatic duct was injured in 14 of 23 patients (11 MPD, 3 branch duct). Contrast leakage from the MPD into peritoneal cavity at ERP confirmed MPD injury in 8 patients, who underwent surgical exploration. Three patients with leakage from a branch duct into the pancreatic parenchyma recovered with conservative treatment. Three patients in whom ERP demonstrated contrast leakage from the MPD confined to the parenchyma underwent successful transpapillary stent insertion with complete resolution of the leak at 3-month follow-up. Patients who underwent ERP more than 72 hours after trauma had a significantly higher rate of pancreas-associated complications and a tendency to remain hospitalized longer than patients who underwent ERP earlier.

CONCLUSION

Early ERP is one of the most useful methods for demonstrating MPD injury. ERP assists with treatment planning based on the degree of pancreatic duct injury.

Traumatic disruption of the pancreatic duct: diagnosis with MR pancreatography

OBJECTIVE. We evaluated the ability of MR pancreatography to reveal traumatic disruptions of the pancreatic duct compared with retrograde pancreatography. CONCLUSION. MR pancreatography is an adequate noninvasive test for the detection of complete traumatic disruptions of the main pancreatic duct. MR pancreatography is especially useful for delineating the segments of the duct that cannot be evaluated with retrograde pancreatography.

Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings

BACKGROUND

The purpose of this study was to determine the utility of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of pancreatic duct trauma and pancreas-specific complications.

METHODS

Ten hemodynamically stable patients with clinically suspected pancreatic injury related to blunt abdominal trauma (n = 8), penetrating trauma (n = 1), or iatrogenic trauma (n = 1) underwent MRCP. Two abdominal radiologists conducted a review of the MRCPs to assess for the presence or absence of pancreatic duct trauma and pancreas-specific complications such as pseudocysts. The MRCP findings were correlated with endoscopic retrograde cholangiopancreatograms (n = 2), surgical findings (n = 1), computed tomographic scans (n = 10), and with clinical, biochemical or imaging follow-up (n = 10).

RESULTS

Diagnostic quality MRCPs were obtained in each of the 10 patients. A mean imaging time of 5 minutes was required to perform the MRCPs. Pancreatic duct injuries were detected in four patients; pseudocysts were detected in three of these four patients. The pancreatic duct injuries in three patients were acute or subacute. In one of the three patients, disruption of a side branch of the pancreatic duct diagnosed with MRCP was not detected with endoscopic retrograde cholangiopancreatography but was confirmed surgically. In the fourth patient, the pancreatic duct injury was chronic; MRCP revealed a posttraumatic stricture in this patient who had sustained blunt abdominal trauma 17 years previously. In the remaining six patients, pancreatic duct trauma was excluded with MRCP. The information derived from the MRCPs was used to guide clinical decision-making in all 10 patients.

CONCLUSIONS

MRCP enables noninvasive detection and exclusion of pancreatic duct trauma and pancreas-specific complications and provides information that may be used to guide management decisions.