Basics
Description
- Direct epigastric blow compressing pancreas against vertebral column resulting in blunt trauma
- Injury to pancreas from penetrating object
- Trauma affects proportionately larger areas, leading to multisystem injuries.
- Children have less protective muscle and SC tissue.
- Malpositioned seat belts and child abuse need to be considered in small children.
- Children will less often present with hypotension.
Etiology
- Penetrating trauma: Most common mechanism
- Blunt trauma: Deep location of pancreas requires significant force to cause injury:
- Steering wheel, seat belts, or bicycle handlebars to abdomen
- In children, evaluate for nonaccidental trauma
Commonly Associated Conditions
90% of pancreatic injuries associated with injuries to adjacent structures:
- Liver, stomach
- Major arteries and veins
- Spleen, kidney
- Duodenum, colon, small bowel
- Common bile duct, gallbladder
- Spine: Chance fracture
Diagnosis
Extent of pancreatic injury may not be apparent on initial evaluation.
Signs and Symptoms
- Abdominal pain:
- Diffuse or epigastric
- Often out of proportion to physical exam and vital signs
- Soft-tissue contusion in upper abdomen
- Injury to lower ribs or costal cartilage
- Acute abdomen, often associated with other intra-abdominal injuries
- Concomitant splenic injury can present initially as dull back pain
- Hypotension
- Grey Turner sign:
- Cullen sign:
History
Concise; details of incident especially important for blunt trauma
Physical Exam
- Inspect for abrasions, contusions, penetrating wounds:
- Must log roll patient for full inspection.
- Look for seat belt " related injuries.
- Auscultate for presence or absence of bowel sounds.
- Palpate to determine location and severity of pain, presence of guarding, and rebound tenderness.
- Rectal exam for occult blood, vaginal exam, or penile exam
- Serial physical exams and vital signs for unidentified injuries
Vascular injury is the most common cause of mortality related to pancreatic injury. Suspicion necessitates immediate evaluation and possible surgical exploration.
Essential Workup
- Pace of workup is dictated by patient condition and other injuries.
- Abdominal CT with IV contrast is essential to evaluate for pancreatic trauma.
- MRCP is being used more frequently in trauma centers to better evaluate ductal injury.
Diagnosis Tests & Interpretation
Lab
- Blood type, screen, or cross-match
- Hematocrit, WBC with differential, complete metabolic profile
- Amylase:
- Not a reliable indicator of pancreatic trauma
- Serial levels may increase sensitivity, but specificity still poor.
- Elevated amylase may be early indicator of potential pancreatic injury.
- Normal amylase does not rule out pancreatic injury.
- More sensitive and specific if detected in diagnostic peritoneal lavage (DPL) fluid
- Lipase:
- No more specific for pancreatic injury
- Urinalysis
- Pregnancy test
- Alcohol and drug screening if indicated
- Prothrombin time/partial thromboplastin time, BUN, and creatinine
Imaging
- Note that all imaging tests may miss pancreatic injury.
- Cervical spine, CXRs, and pelvis films as for all blunt trauma patients
- Bedside US/FAST scan
- CT scan with IV contrast, helical/MDCT if available:
- Shows better contrast enhancement of pancreatic parenchyma than standard scanning
- MDCT is particularly useful in pediatric populations
- Magnetic retrograde cholangiopancreatography:
- Noninvasive evaluation of injury to ductal components
- Endoscopic retrograde cholangiopancreatography:
- Useful for patients with persistent hyperamylasemia
- Unexplained abdominal symptoms
- Some advocating early use to minimize complications
- Operative exploration and intraoperative cholangiogram remains the ideal diagnostic modality, particularly if patient is unstable.
Diagnostic Procedures/Surgery
DPL to identify intraperitoneal injuries:
- Check fluid for amylase level.
- May still miss significant pancreatic injury
Differential Diagnosis
Other or associated abdominal traumatic injuries
Treatment
Pre-Hospital
Transport to closest trauma center.
Initial Stabilization/Therapy
- Airway management, resuscitation as indicated with crystalloids, colloids, or blood products
- Nasogastric-tube suction may be especially helpful in the setting of pancreatic trauma.
General Measures
Follow standard trauma treatment for blunt abdominal trauma:
- Penetrating trauma:
- Tetanus prophylaxis and broad-spectrum antibiotic therapy
- Intra-abdominal injury requiring operative intervention:
- Broad-spectrum antibiotic therapy
- Must cover for colonic bacteria:
- Aerobic: Escherichia coli, Enterobacter, Klebsiella, Enterococcus
- Anaerobic: Bacteroides fragilis, Clostridium, Peptostreptococcus
Ed Treatment/Procedures
Follow ABCDE of trauma and resuscitate unstable patient with emergent surgical consultation or transfer to trauma center as indicated:
- Evaluate for associated abdominal injury.
- Choose imaging modality for rapid evaluation (CT and/or MRCP).
- Early identification of ductal injuries has been shown to reduce morbidity and mortality.
- Surgical: Pancreaticoduodenectomy, distal pancreatectomy, endoscopic stent (controversial), sump/closed suction drainage
- East Trauma Guidelines 2009
- Level III evidence: Grade I and II injuries: Drainage Grade III " V injuries: Resection and drainage
Medication
- Adults:
- Piperacillin/tazobactam 3.375 g IV OR
- Cefotetan: 2 g IV + gentamicin 2 mg/kg IV OR
- Cefoxitin: 2 g IV + gentamicin 2 mg/kg IV OR
- Ceftriaxone: 1 " 2 g IV + Flagyl 15 mg/kg IV OR
- Clindamycin: 600 mg IV + gentamicin 2 mg/kg IV
- Children:
- Cefotetan: 20 mg/kg IV + gentamicin 2 mg/kg IV OR
- Cefoxitin: 40 mg/kg IV + gentamicin 2 mg/kg IV OR
- Ceftriaxone: 50 mg/kg per dose IV + Flagyl 15 mg/kg IV
First Line
Ceftriaxone and Flagyl or piperacillin/tazobactam or carbapenem:
- Goal is to choose broad-spectrum coverage with both aerobic and anaerobic coverage, particularly of enteric gram-negative organisms.
Second Line
Addition of an aminoglycoside, as it has good activity in an alkaline environment:
- Particularly useful if patient is unstable for broader gram-negative coverage
Adjunct Therapy
There is no good evidence to support the use of octreotide as studies still conflict on the benefits and adverse effects.
Follow-Up
Disposition
Admission Criteria
- All patients with suspected pancreatic injuries must be admitted.
- Abdominal pain after blunt trauma requires serial exam and observation for 24 " 72 hr.
- Intoxicated trauma patient requires admission and serial exams for unidentified injury.
Discharge Criteria
Only for very minor trauma and with no evidence of pancreatic or any other intra-abdominal injury with appropriate follow-up and return precautions
Issues for Referral
- Patient with surgical drains or complications such as fistula formation may need further surgical, GI, and wound care evaluations.
- Most patients need close monitoring and follow-up within 1 wk.
Followup Recommendations
Delayed presentation of pancreatic injury is rare, but complications may arise and should be considered:
- Pancreatitis, pseudocysts, vascular aneurysms (such as splenic artery)
- Rare for exocrine or endocrine dysfunction to occur unless a majority of the pancreas is resected/destroyed:
- Evaluate for glucose intolerance and digestive abnormalities
Pearls and Pitfalls
- Always consider pancreatic injury when evaluating abdominal or back trauma, both blunt and penetrating.
- Beware of nearby vascular injuries.
- Assess for related injuries.
- Choose the best imaging modality and obtain as rapidly as possible.
- Penetrating trauma or unstable patients should be rapidly prepared for surgical exploration.
Additional Reading
- Ahmed N, Vernick JJ. Pancreatic injury. South Med J. 2009;102(12):1253 " 1256.
- Almaramhy HH, Guraya SY. Computed tomography for pancreatic injuries in pediatric blunt abdominal trauma. World J Gastrointest Surg. 2012;4(7):166 " 170.
- Beckingham IJ, Krige JE. ABC of diseases of liver, pancreas and biliary system: Liver and pancreatic trauma. BMJ. 2001;322:783 " 785.
- Rekhi S, Anderson SW, Rhea JT, et al. Imaging of blunt pancreatic trauma. Emerg Radiol. 2010;17(1):13 " 19.
- Vasquez JC, Coimbra R, Hoyt DB, et al. Management of penetrating pancreatic trauma: An 11-year experience of a level-1 trauma center. Injury. 2001;32(10):753 " 759.
- Wolf A, Bernhardt J, Patrzyk M, et al. The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma. Surg Endosc. 2005;19(5):665 " 669.
Codes
ICD9
- 863.84 Injury to pancreas, multiple and unspecified sites, without mention of open wound into cavity
- 863.94 Injury to pancreas, multiple and unspecified sites, with open wound into cavity
ICD10
- S36.209A Unspecified injury of unspecified part of pancreas, initial encounter
- S36.229A Contusion of unspecified part of pancreas, initial encounter
- S36.239A Laceration of unspecified part of pancreas, unspecified degree, initial encounter
- S36.299A Other injury of unspecified part of pancreas, initial encounter
SNOMED
- 61823004 Injury of pancreas (disorder)
- 210150004 Closed injury of pancreas (disorder)
- 282439006 Tear of pancreas (disorder)
- 262827003 Contusion of pancreas (disorder)
- 210160008 Injury to pancreas - open (disorder)