The pancreas is uncommonly injured in blunt trauma. However, pancreatic trauma has a high morbidity and mortality rate. Imaging features range from subtle to obvious.
The pancreas is injured in ~7.5% (range 2-13%) of blunt trauma cases 1,3,7. Motor vehicle accidents account for the vast majority of cases. Penetrating trauma constitutes up to a third of causes in some studies 7.
The classic triad of fever, raised white cell count, and amylase is rare. Serum amylase or lipase are elevated in ~80% of cases 1 but distinguishing between a raised amylase or lipase as an acute phase reactant or resulting from a pancreatic injury is difficult.
Non specific clinical signs are a seat belt sign or flank hematoma.
The pancreatic body accounts for two-thirds of injuries with ~10% occurring each in the head, neck and tail 1. Due to its retroperitoneal location and oblique course, it is prone to compression against the vertebral column 1-3,7.
Due to the course of the main pancreatic duct, it may be injured in trauma to any part of the pancreas.
- pancreatic contusion: indistinct region of parenchymal edema
- laceration: discrete linear or branching partial thickness tear
- pancreatic transection: full-thickness tear
- pancreatic comminution (fracture): shattered pancreas
- pancreatic hematoma
- pancreatic pseudocyst
For the AAST grading system of injuries, the proximal pancreas is defined as the gland to the right of the SMV-portal vein axis whereas the distal pancreas is to the left of the axis.
See main article: grading of pancreatic injuries.
It is uncommonly (<10%) an isolated injury and other organs that are also injured include (in decreasing order 7):
- ERCP can also be used to image the pancreatic duct and any associated injury, although it's main role is to provide access to stent the pancreatic duct when injury is confirmed by MRCP
CT is the intiial modality of choice in assessment of injuries of the abdomen. Standard IV contrast protocols in portal venous phase most commonly used however some trauma centers advocate for an addition arterial phase 7.
- direct signs 1,2,7
- hypodense laceration or comminution of the pancreatic parenchyma
- heterogeneous parenchymal enhancement
- enlargement of the pancreas
- fluid collections (pseudocyst or abscess) communicating with the pancreatic duct
- secondary signs
- injury to the pancreatic duct may not be seen directly but is inferred by the grading of the injury 1
Low monoenergetic (monoE) reconstructions on spectral scanners has been shown to increase injury diagnostic accuracy 7,8.
- MRCP can be used to image the pancreatic duct and any associated injury
Treatment and prognosis
Delayed diagnosis raises both the mortality and morbidity of traumatic pancreatic injuries, both of which are high, with a mortality rate of up to 20% 3.
Injuries with pancreatic duct disruption are more likely to undergo endoscopic stenting whereas surgical intervention is preferred for injuries not involving the pancreatic duct 1.
Complications of pancreatic trauma occur in up to 20% of patients and are more likely in higher grade injuries. Complications include:
- pancreatitis: occurs in ~7.5% (range 6-10%)
- fistula (more common with pancreatic duct disruption)
- abscess and sepsis (more common with pancreatic duct disruption)
- from the pancreas
- from a pseudoaneursym (e.g. splenic or gastroduodenal artery)
- pancreatic pseudocyst
- 1. Gupta A, Stuhlfaut JW, Fleming KW et-al. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. 2004;24 (5): 1381-95. doi:10.1148/rg.245045002 - Pubmed citation
- 2. Patel SV, Spencer JA, el-Hasani S et-al. Imaging of pancreatic trauma. Br J Radiol. 1999;71 (849): 985-90. Pubmed citation
- 3. Jeffrey RB, Federle MP, Crass RA. Computed tomography of pancreatic trauma. Radiology. 1983;147 (2): 491-4. Pubmed citation
- 4. Oniscu GC, Parks RW, Garden OJ. Classification of liver and pancreatic trauma. HPB (Oxford). 2006;8 (1): 4-9. doi:10.1080/13651820500465881 - Free text at pubmed - Pubmed citation
- 5. Martin L. Gunn. Pearls and Pitfalls in Emergency Radiology. ISBN: 9781139619899
- 6. J. C. Brandon, S. D. Izenberg, P. A. Fields, C. Evankovich, G. Wilson, S. K. Teplick. Pancreatic clefts caused by penetrating vessels: a potential diagnostic pitfall for pancreatic fracture on CT. (2000) Emergency Radiology. 7 (5): 283. doi:10.1007/PL00011842
- 7. Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN. Pancreatic Trauma: Imaging Review and Management Update. (2021) Radiographics : a review publication of the Radiological Society of North America, Inc. 41 (1): 58-74. doi:10.1148/rg.2021200077 - Pubmed
- 8. Sugrue G, Walsh JP, Zhang Y, Niu B, Macri F, Khasanova E, Metwally O, Murray N, Nicolaou S. Virtual monochromatic reconstructions of dual energy CT in abdominal trauma: optimization of energy level improves pancreas laceration conspicuity and diagnostic confidence. (2021) Emergency radiology. 28 (1): 1-7. doi:10.1007/s10140-020-01791-4 - Pubmed
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