Overview
Definition:
Pancreatic injury refers to damage to the pancreas, a vital organ involved in digestion and hormone production
Injuries can be blunt or penetrating and are classified based on severity and location (proximal vs
distal).
Epidemiology:
Pancreatic injuries account for approximately 0.05-0.1% of all trauma admissions
Blunt trauma is more common, often associated with high-speed motor vehicle accidents or falls
Penetrating injuries are typically from stab or gunshot wounds.
Clinical Significance:
Pancreatic injuries are challenging due to the organ's retroperitoneal location and enzymatic content, leading to significant morbidity and mortality if not managed appropriately
Accurate diagnosis and timely intervention are critical for patient outcomes and preventing complications like pseudocysts, abscesses, and fistulas.
Clinical Presentation
Symptoms:
Epigastric pain, often radiating to the back
Nausea and vomiting
Abdominal distension
Fever may indicate associated organ injury or peritonitis
Jaundice is less common but suggests bile duct involvement.
Signs:
Tenderness in the epigastrium or upper abdomen
Guarding and rigidity suggesting peritoneal irritation
Bruising or ecchymosis in the flank (Grey-Turner's sign) or periumbilical area (Cullen's sign) are late signs of retroperitoneal hemorrhage
Decreased bowel sounds.
Diagnostic Criteria:
Diagnosis relies on clinical suspicion, physical examination, and imaging
The American Association for the Surgery of Trauma (AAST) organ injury scale for the pancreas is used for grading severity.
Diagnostic Approach
History Taking:
Mechanism of injury (blunt vs
penetrating)
Force and direction of impact
Associated injuries
Alcohol consumption history as a risk factor for chronic pancreatitis and impaired healing.
Physical Examination:
Complete abdominal examination, including assessment for signs of peritonitis
Examination of the chest and back for associated injuries
Palpation for masses or tenderness
Digital rectal examination and evaluation of genitalia in cases of pelvic trauma.
Investigations:
Laboratory tests: Complete blood count (CBC) for hemoconcentration and infection
Serum amylase and lipase levels (may be normal in up to 50% of severe injuries, but elevated levels are suggestive)
Liver function tests (LFTs) to assess for biliary involvement
Arterial blood gas (ABG) for acid-base status
Imaging: CT scan of the abdomen and pelvis with intravenous contrast is the gold standard, identifying direct pancreatic injury, fluid collections, and associated organ damage
Ultrasound can be useful for initial assessment and identifying fluid collections
Endoscopic retrograde cholangiopancreatography (ERCP) may be indicated for suspected ductal disruption, especially in distal injuries.
Differential Diagnosis:
Gastric or duodenal perforation
Mesenteric injury
Splenic injury
Renal contusion or laceration
Biliary tract injury
Non-traumatic causes of pancreatitis.
Management
Initial Management:
Resuscitation with intravenous fluids and blood products as needed
Analgesia to control pain
Nasogastric tube decompression if ileus is present
Broad-spectrum antibiotics to cover gut flora if a hollow viscus is injured or if there is significant pancreatic necrosis
Initial management is often conservative, focusing on hemodynamic stability.
Medical Management:
Aggressive fluid resuscitation
Pain control
Nutritional support, including early enteral feeding via a feeding jejunostomy if possible, to reduce the risk of stress ulcers and promote healing
Total parenteral nutrition (TPN) as a second-line option if enteral feeding is not feasible.
Surgical Management:
Indications for surgery include hemodynamic instability, evidence of major ductal disruption, associated hollow viscus injury, or failure of non-operative management
Proximal injuries often involve the head of the pancreas and may require pancreatoduodenectomy (Whipple procedure) or internal drainage
Distal injuries involving the body and tail are typically managed with distal pancreatectomy, often with splenic preservation (e.g., Warshaw technique)
For contained injuries or mild ductal disruption, non-operative management with close observation and drainage of collections may be sufficient
Management decisions are guided by the AAST grade, patient stability, and associated injuries.
Supportive Care:
Close monitoring of vital signs, urine output, and abdominal examination
Management of pain
Monitoring for complications such as infection, fluid collections, and fistula formation
Strict glycemic control is important, especially in pancreatic head injuries affecting endocrine function.
Complications
Early Complications:
Hemorrhage
Pancreatic pseudocyst formation
Pancreatic abscess
Acute pancreatitis
Wound infection
Enterocutaneous fistula.
Late Complications:
Chronic pancreatitis
Pancreatic duct strictures
Pancreatic insufficiency (exocrine and endocrine)
Adhesive small bowel obstruction
Incisional hernia.
Prevention Strategies:
Judicious surgical technique, especially during resection
Early recognition and drainage of pseudocysts and abscesses
Prompt management of fistulas
Adequate nutritional support
Prophylactic antibiotics in specific high-risk scenarios.
Prognosis
Factors Affecting Prognosis:
Severity of the pancreatic injury (AAST grade)
Presence of associated injuries
Hemodynamic stability
Promptness and appropriateness of treatment
Development of complications like infection or major ductal disruption.
Outcomes:
For low-grade injuries (AAST I-II) managed non-operatively, outcomes are generally good with minimal long-term sequelae
High-grade injuries (AAST III-V) are associated with higher rates of complications, prolonged hospitalization, and increased mortality
Pancreatic fistulas, pseudocysts, and the need for pancreatoduodenectomy portend a worse prognosis.
Follow Up:
Regular follow-up with clinical assessment and imaging (CT scan or ultrasound) to monitor for pseudocyst resolution, fistula closure, and development of chronic changes
Assessment of exocrine and endocrine function (e.g., HbA1c, fecal elastase) may be necessary long-term.
Key Points
Exam Focus:
Distinguish management of proximal (head) vs
distal (body/tail) pancreatic injuries
AAST grading is crucial
Indications for operative vs
non-operative management
Common surgical procedures: distal pancreatectomy, pancreatoduodenectomy, internal drainage
Complications like pseudocyst and fistula are high-yield.
Clinical Pearls:
Serum lipase is more specific than amylase for pancreatic injury
CT is the imaging modality of choice
Consider early enteral feeding to improve outcomes
Splenic preservation during distal pancreatectomy is desirable
Management requires a multidisciplinary approach.
Common Mistakes:
Delayed diagnosis due to normal initial amylase/lipase
Inadequate resuscitation
Conservative management of significant ductal injuries
Failure to address associated injuries
Overlooking early signs of complications like infection or pseudocyst.