Figure 1
CT
Abdominal CT with contrast. A hypodense focus is observed between the head and the body of the pancreas, that doesn't enhance with contrast. There is peri-duodenal and peri-pancreatic fluid (red arrows).
Pancreatic injury due to blunt trauma
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsBarreda-Solana M, Oprisan A, Picado-Bermúdez, Viguer-Benavent R, Pérez-Girbés A.
Connected authors
28 years, male
Clinical History
A 28-year-old male patient with no past medical history presents to the emergency department with abdominal pain after being kicked in the epigastrium while playing soccer. In the initial blood tests transaminase elevation was documented. Due to the suspicion of liver injury, an imaging study was requested.
Imaging Findings
In the abdominal CT a hypodense focus is observed between the head and the body of the pancreas, that doesn't enhance with contrast. There is peri-duodenal and peri-pancreatic fluid associated (Fig.1).
Magnetic resonance cholangiopancreatography (MRCP) was performed to evaluate the status of the main pancreatic duct. The common hepatic duct and the common bile duct are clearly visualised, while the integrity of the pancreatic duct cannot be determined (Fig.2a).
In the T1-weighted images after the gadolinium chelate administration, a complete laceration between the head and body of the pancreas is observed (Fig.2b), with a significant increase of the free intra-abdominal fluid in the T2-weighted images (Fig. 2c).
Pancreatic duct rupture was confirmed with an endoscopic retrograde cholangiopancreatography (ERCP). Images show contrast leak after its injection through the proximal pancreatic duct (Fig.3).
Magnetic resonance cholangiopancreatography (MRCP) was performed to evaluate the status of the main pancreatic duct. The common hepatic duct and the common bile duct are clearly visualised, while the integrity of the pancreatic duct cannot be determined (Fig.2a).
In the T1-weighted images after the gadolinium chelate administration, a complete laceration between the head and body of the pancreas is observed (Fig.2b), with a significant increase of the free intra-abdominal fluid in the T2-weighted images (Fig. 2c).
Pancreatic duct rupture was confirmed with an endoscopic retrograde cholangiopancreatography (ERCP). Images show contrast leak after its injection through the proximal pancreatic duct (Fig.3).
Discussion
Pancreatic trauma is a rare entity, it occurs in less than 10% of all blunt traumatic abdominal injuries and is usually secondary to direct impacts [1]. The injury mechanism is due to the anteroposterior compression of the pancreas against the spine. The body of the pancreas is the most frequently affected portion in the majority of cases [1, 2].
At the beginning symptoms can be nonspecific and blood tests can be normal. A typical clinical triad in pancreatic trauma has been described, it consists of upper abdominal pain, leukocytosis and elevated serum amylase [2, 3], all of the three were present in our patient.
This pathology is associated with high morbidity and mortality due to the development of numerous complications such as pancreatic fistulas, abscesses, haemorrhage, pancreatitis, pseudo-cysts and endocrine insufficiency [1].
The most used classification to evaluate the degree of severity of pancreatic trauma is the one proposed by the American Association for the Surgery of Trauma (AAST), which classifies pancreatic trauma into each of 5 degrees [3, 4]. The main factors affecting the morbidity and mortality rate of patients are the location of the lesion (proximal lesions are more serious and they are usually associated with injury of other structures: vascular, biliary, portal, mesenteric, etc.) and the compromise of the main pancreatic duct [2, 3].
The treatment of choice is decided upon according to the severity of the pancreatic injury, principally determined by the involvement of the pancreatic duct [3, 4]; if it is not injured, management will be conservative, with drainage of possible collections. In case of pancreatic duct injury, treatment willl mainly be surgical and the technique will be chosen depending on the lesion, from focal distal pancreatectomy to pancreatoduodenectomy. One important conservative method for treating the ruptured duct is endoscopic stenting to prevent pancreatic juice leakage [3, 4].
In summary, pancreatic injuries due to blunt trauma are rare and may go unnoticed at first. Morbidity and mortality rates are high if timely diagnosis and treatment are not established. That is why a high suspicion is essential for these patients in order to perform adequate imaging techniques and offer the best treatment.
Our patient's evolution was not favourable with the development of infected necrotic collections, peripancreatic fistulas and necrosis of the pancreas and duodenum, which required multiple surgical interventions and per-cutaneous drainage.
Written informed patient consent for publication has been obtained.
At the beginning symptoms can be nonspecific and blood tests can be normal. A typical clinical triad in pancreatic trauma has been described, it consists of upper abdominal pain, leukocytosis and elevated serum amylase [2, 3], all of the three were present in our patient.
This pathology is associated with high morbidity and mortality due to the development of numerous complications such as pancreatic fistulas, abscesses, haemorrhage, pancreatitis, pseudo-cysts and endocrine insufficiency [1].
The most used classification to evaluate the degree of severity of pancreatic trauma is the one proposed by the American Association for the Surgery of Trauma (AAST), which classifies pancreatic trauma into each of 5 degrees [3, 4]. The main factors affecting the morbidity and mortality rate of patients are the location of the lesion (proximal lesions are more serious and they are usually associated with injury of other structures: vascular, biliary, portal, mesenteric, etc.) and the compromise of the main pancreatic duct [2, 3].
The treatment of choice is decided upon according to the severity of the pancreatic injury, principally determined by the involvement of the pancreatic duct [3, 4]; if it is not injured, management will be conservative, with drainage of possible collections. In case of pancreatic duct injury, treatment willl mainly be surgical and the technique will be chosen depending on the lesion, from focal distal pancreatectomy to pancreatoduodenectomy. One important conservative method for treating the ruptured duct is endoscopic stenting to prevent pancreatic juice leakage [3, 4].
In summary, pancreatic injuries due to blunt trauma are rare and may go unnoticed at first. Morbidity and mortality rates are high if timely diagnosis and treatment are not established. That is why a high suspicion is essential for these patients in order to perform adequate imaging techniques and offer the best treatment.
Our patient's evolution was not favourable with the development of infected necrotic collections, peripancreatic fistulas and necrosis of the pancreas and duodenum, which required multiple surgical interventions and per-cutaneous drainage.
Written informed patient consent for publication has been obtained.
Differential Diagnosis List
Proximal laceration of the pancreas affecting the main pancreatic duct.
Pancreatic clefts
Pancreatitis
Final Diagnosis
Proximal laceration of the pancreas affecting the main pancreatic duct.
References
[1] Gupta A, et al. (2004) Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics Sep-Oct;24(5):1381-95. (PMID: 15371615)
[2] Linsenmaier U, et al. (2008) Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology. Radiographics Oct;28(6):1591-602. (PMID: 18936023)
[3] Debi U, et al. (2013) Pancreatic trauma: A concise review. World J Gastroenterol 21;19(47):9003-11. (PMID: 24379625)
[4] Menahem B, et al. (2016) Conservative and surgical management of pancreatic trauma in adult patients. Hepatobiliary Surg Nutr 5(6):470-477. (PMID: 28124001)
Case information
| URL: | https://eurorad.org/case/15808 |
| DOI: | 10.1594/EURORAD/CASE.15808 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Colangio-MRI
Colangio-MRI. The common hepatic duct and the common bile duct are clearly visualised, but the integrity of the pancreatic duct cannot be identified.
T1-weighted images with contrast. A complete laceration between the head and body of the pancreas is observed, seen in a hypointense focus.
Fat-saturated T2-weighted images. Significant increase of the free intra-abdominal fluid.
Figure 3
ERCP
An ERCP is performed. Pancreatic duct rupture was confirmed, the image shows contrast leak after its injection through the proximal pancreatic duct.
CT
Abdominal CT with contrast. A hypodense focus is observed between the head and the body of the pancreas, that doesn't enhance with contrast. There is peri-duodenal and peri-pancreatic fluid (red arrows).
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
Colangio-MRI
Colangio-MRI. The common hepatic duct and the common bile duct are clearly visualised, but the integrity of the pancreatic duct cannot be identified.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
T1-weighted images with contrast. A complete laceration between the head and body of the pancreas is observed, seen in a hypointense focus.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
Fat-saturated T2-weighted images. Significant increase of the free intra-abdominal fluid.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
ERCP
An ERCP is performed. Pancreatic duct rupture was confirmed, the image shows contrast leak after its injection through the proximal pancreatic duct.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
ACIM, Hospital Universitario y Politécnico La Fe, Valencia, Spain.