The pancreas is uncommonly injured in blunt trauma. However, pancreatic trauma has a high morbidity and mortality. Imaging features may be subtle.
The pancreas is injured in ~7.5% (range 2-13%) of blunt trauma cases 1,3. Motor vehicle accidents account for the vast majority of cases.
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/lipase as an acute phase reactant or resulting from a pancreatic injury is difficult.
The pancreatic body accounts for two-thirds of injuries with ~10% occurring each in the head, neck and tail 1.
The pancreas is prone to crush injuries against the vertebral column 1-3:
- pancreatic laceration: partial thickness tear of the pancreas
- pancreatic transection: full thickness tear of the pancreas
- pancreatic comminution (fracture): shattered pancreas
- pancreatic haematoma
- pancreatic pseudocyst
See main article: grading of pancreatic injuries.
It is uncommonly (<10%) an isolated injury and other organs that are also injured include:
- direct signs 1-2
- hypodense laceration or comminution of the pancreatic parenchyma
- heterogeneous parenchymal enhancement
- enlargement of the pancreas
- fluid collections (pseudocyst, abscess or haematoma) communicating with the pancreatic duct
- secondary signs
- peripancreatic fat stranding, fluid or haematoma between the pancreas and splenic vein 1-2
- peripancreatic fluid
- thickening of Gerota’s fascia
- injury to the pancreatic duct may not be seen directly but is inferred by the grading of the injury 1
- MRCP can be used to image the pancreatic duct and any associated injury
- 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
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 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)
- pancreatic pseudocyst
- pancreatic clefts which are most prominent at the junction of the body and neck 6.
- cystic neoplasm (cystic pancreatic mass differential diagnosis)
- solid neoplasm
- nonepithelial pancreatic neoplasms
pancreatitis (mnemonic for the causes)
- gallstone pancreatitis
- interstitial oedematous pancreatitis
- necrotising pancreatitis
- haemorrhagic pancreatitis
- revised Atlanta classification of acute pancreatitis
- chronic pancreatitis
- Ascaris-induced pancreatitis
- tropical pancreatitis
- autoimmune pancreatitis
- emphysematous pancreatitis
- hereditary pancreatitis
- pancreatitis associated with cystic fibrosis
- segmental pancreatitis
- acute pancreatitis
- pancreatic atrophy
- pancreatic lipomatosis
- pancreatic trauma
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- 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. Brandon JC et al. Pancreatic clefts caused by penetrating vessels: a potential diasgnostic pitfall for pancreatic fracture on CT. Emerg Radiol 2000 :7(5):283-6.