SOLID ORGAN INJURIES FOLLOWING ABDOMINAL

TRAUMAMODERATORS – PROF DR R.K. DEKA

PROF DR H.K. BHATTACHARYYA

PROF DR A. AHMED

PRESENTED BY- DR AYMEN AHMAD KHAN

PGT SURGERY

INTRODUCTION

Motor vehicle accidents are responsible for 75% of all blunt trauma abdominal injuries

More common in elderly due to less resilience.

Blunt injuries causes solid organ trauma (spleen, liver and kidneys) more often than hollow viscera.Multi organ injury and multiple system injury are also more common in blunt injury than in other types.

Spleen is most common intra abdominal organ to be injured followed by liver.

ORGAN INJURIES

SOLID ORGANS-

• Solid organs most commonly injured in blunt traumas

• In decreasing incidence of injury

• Spleen, liver, kidneys, intraperitoneal small bowel, bladder, colon, diaphragm, pancreas and duodenum

HOLLOW VISCERA:

- duodenum commonly injured

- Small bowel injured at relatively fixed areas (duodenojejunal flexure and ileocaecal junction) by shearing force

- Colon relatively protected.

- Gaseous distension of caecum – most vulnerable part as fixed.

- Stomach rarely injured – compression cause esophagogastric junction bursting

RETROPERITONEUM AND UROGENITAL TRACT

• Kidney injury - common next to spleen and liver

• Pancreatic injury - 4% cases of trauma

• Bladder - most commonly injured extra peritoneally by shearing at the vesico urethral junction.

- intraperitoneally by blunt force on distended bladder

• Rupture of prostatic urethra by shear forces is commonly seen with haemorrhage

CHILDHOOD TRAUMA• Blunt trauma secondary to MVAs, falls or child abuse is

primarily responsible for 90% of childhood injuries.

• Predominance - Solid organ abdominal injuries.

• Non-op. management – 90% success rate (standard of care in solid organ injuries)

• Overall mortality – approx 15% or < (if major vascular injuries excluded)

• Mortality from severe blunt trauma abdomen is higher than penetrating injuries

MECHANISM OF INJURY

• Direct application of a blunt force to the abdomenCRUSHING

• Sudden decelerations apply a shearing force across organs with fixed attachmentsSHEARING

• Raised intraluminal pressure by abdominal compression accurately in hollow organs can lead to rupture

BURSTING

• Disruption of bony areas by blunt trauma may generate bony spicules that can cause secondary penetrating injury

PENETRATION

BLUNT ABDOMINAL TRAUMA

• Direct impact or movement of organs

• Compressive, stretching or shearing forces

• Solid Organs > Blood Loss

• Hollow Organs > Blood Loss and Peritoneal Contamination

• Retroperitoneal > Often asymptomatic initially

PRESENTATION

• Varies widely from haemodynamic stability with minimal abdominal signs to complete cardiovascular collapse and may change from one to the other with alarming rapidity

INITIAL ASSESSMENT

Whether the patient is haemodynamically-stable -unstable

FIRST PRIORITIES PROTOCOL : • Brief clinical

examination to evaluate ABC along with cardiovascular status with blood pressure and pulse measurement

Accordingly, resuscitation and management of shock by • maintenance of ABC • IV fluids• nasogastric tube insertion

• Catheterization

SECOND PRIORITIES PROTOCOL

Physical examination

Base line investigations

Four quadrant tap

Diagnostic peritoneal lavage (DPL)

Ultrasound – FAST (focus assessment with sonography for trauma)

Abdominal CT scan

Diagnostic laparoscopy

Laparotomy

PHYSICAL EXAMINATION

General Examination : relating to hemodynamic stability

Abdominal findings:

Inspection : • for abdominal distension • for contusions or abrasions• lap belt ecchymosis – mesenteric, bowel, and lumbar spine

injuries • periumblical (Cullen sign) and flank (Grey Turner Sign)

ecchymosis – retroperitoneal haematoma

Palpation : • for tenderness, guarding and/or rigidity, rebound tenderness –

hemoperitoneum Percussion :

• Dullness/ shifting dullness – intrabdominal collection

Auscultation : • bowel sounds present/absent.

Rectal findings

Check for gross blood - pelvic fracture

Determine prostate position – high riding prostate – urethral injury

Assess sphincter tone – neurologic status

DIAGNOSTIC STRATEGY

to identify those with

injuries

to decide which

ones need laparotom

y

how quickly

this must be

undertaken

BASIC INVESTIGATIONS• Complete haemogram with hematocrit, ABG, Electrocardiogram

• Renal function tests• Urine analysis – • +nce of hematuria – genito urinary injury

• -nce of hematuria – does not rule out it

• Serum amylase / lipase or liver enzymes - se -suspicion of intraabdominal injuries

• Chest radiograph – • Pneumothorax/hemothorax• Raised left/right hemidiaphragm –

perisplenic/hepatic hematoma.• Lower ribs fracture – liver/spleen injury.• Abdominal contents in the chest – • ruptured

hemidiaphragm

• Abdominal radiographs –- Pneumoperitoneum – perforation of

hollow viscus- Ground glass appearance –massive

hemoperitoneum

- Dilated gut loops- retroperitoneal hematoma or injury

- Retroperitoneal air outlining the right kidney – duodenal injury

- Double wall sign – air inside and outside the bowel

- Distortion or enlargement of outlines of viscera – hematoma in relation to respective organs

- Medial displacement of stomach – splenic hematoma

- Obliteration of Psoas shadow – retroperitoneal bleeding

- Pelvic bone fracture – bladder/urethral/rectal injury

- Fracture vertebra – ureter injury / retroperitoneal hematoma

INDICATIONS FOR FURTHER TESTING

Unexplained haemorrhagic shock

Major chest or pelvic injuries

Abdominal tenderness

Diminished pain response due to - • Intoxication • Depressed level of consciousness • Distracting pain• Paralysis

Inability to perform serial examination

FOUR QUADRANT

TAP:

Overall accuracy – about 90%

Positive tap – obtaining 0.1 ml or more of non clotting

blood

Negative tap does not rule

out haemorrhage

DIAGNOSTIC PERITONEAL

LAVAGE

Criteria for positive tap –

Gross bloody tap

>1,00,000 RBCs per mm

> 500 white blood cells per mm

Elevated amylase level

Presence of bile or bacteria or faeces

ULTRASOUND FAST EXAMINATIONS (focused assessment with sonography

for trauma).

ADVANTAGES

Inexpensive, noninvasive and

portable

Performed by emergency

physicians and surgeons trained

in performing FAST

examinations.

Avoids risks associated with contrast media

Confirms presence of hemoperitoneum in minutes•Deceases time to laparotomy

•Great adjunct during multiple casualty disasters

Serial examination can detect ongoing hemorrhage

Differentiates pulseless

electrical activity from extreme hypotension

DISADVANTAGES

A minimum of 70 ml of

intraperitoneal fluid for positive

study.Accuracy is

dependent on operator /

interpreter skill and is decreased

with prior abdominal surgery.

Technically difficult with – obese, ileus or subcutaenous emphysema is

present

Does not define exact cause of

hemoperitoneum

Sensitivity is low for small-bowel and pancreatic

injury

Sensitivity – 69%-99%

Technique -Four basic transducer positions used

to find abdominal fluid.

ABDOMINAL CT SCAN

-Latest generation of helical and

multislice scanners provides rapid and

accurate diagnostic

information.

-Criterion standard for solid organ

injuries.

-Help quantitate the amount of blood in the

abdomen and can reveal individual

organs with precision

Diagnostic Modalities in Abdominal Trauma

* Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in blunt abdominal trauma. J Trauma 29:242, 1999.** Meyer D M, Thal E R, Weigelt J A, et al: The role of abdominal CT in the evaluation of stab wounds to the back. J Trauma 29:1226, 1999.

LAPAROSCOPY

ADVANTAGES

extent of organ injuries and determines the need for laparotomyDefines which intraabdominal injuries may be safely managed nonsurgically

More sensitive than DPL or CT in uncovering - • Diaphragmatic injuries• Hollow viscus injuries

Surgery can be done in same sitting • With laparoscope with minimal

trauma • Open surgery

DISADVANTAGES:

pneumoperitoneum may elevate ICP

General anesthesia usually necessary

Patient must be hemodynamically stable

LAPAROTOMY

Peritonitis (gross blood, bile or faeces)

Pneumoperitoneum or pneumoretroperitoneu

m

Evidence of diaphragmatic defect

Gross blood from stomach or rectum

Abdominal distension with hypotension

Positive diagnostic test for an injury requiring

operative repair

INDICATIONS

PROTOCOL FOR BLUNT TRAUMA ABDOMEN MANAGEMENT

SPLENIC INJURYThe spleen is the intra-abdominal organ most frequently injured in blunt traumaSpleen lies in posterior portion of lt upper quadrant, deep to ninth ,tenth and eleven ribsConvex surface lies under lt hemidiaphargm

Concavities on medial side due to impression by neighbouring structures

Average length 7-11cm

Weight 150 grams (70-250)

Tail of pancreas lies incontact with spleen in 30% and within 1cm in 70%

Arterial Supply and Venous drainage

Splenic artery provides major blood supplyArises from coeliac artery (ocassionaly aorta or SMA)

Tortrous course (average 13 cm)

Small blood supply from short gastric vessels.

Venous drainage is through splenic vein

Joins superior mesenteric vein to form portal vein

SUSPENSORY LIGAMENTS

Provide attachment of

spleen with adjacent

structures

These ligaments are avascular

except gastrosplenic

ligament (containing short

gastric and gastroepiploic

artery)

GASTROSPLENIC SPLENORENAL

SPLENOPHRENIC SPLENORENAL

PRESENTATION

Patient may present with the

upper abdominal or

flank pain Referred pain to

the shoulder

(kehr sign)

Some may be

asymptomatic

Physical examination is insensitive and

non specific.

Pt may have signs of lt upper

quadrant tenderness or

signs of generalized peritoneal irritation.

May present with tachycardia ,Tachypnea, anxiety ,

Hypotension (shock)

Organ Injury Scaling-American Association of the Surgery of

Trauma (OIS-AAST)

MANAGEMENT

Nonoperative management of splenic injury is successful

in >90% of children, irrespective of the grade of

splenic injury.

Non operative management successful in adults 65%

unstable patients suspected of splenic injury and intra-

abdominal hemorrhage should undergo exploratory

laparotomy and splenic repair or removal.

blunt trauma patient with evidence of hemodynamic instability unresponsive to

fluid challenge with no other signs of external hemorrhage should be considered to have a life-threatening solid organ (splenic) injury until proven

otherwise.

FLOWCHART FOR MANAGEMENT

Criteria for non

operative managem

ent

Haemodynamic stability

Negative

abdominal scan

Absence of contrast

extravasation on CT

Absence of other clear

indications for exploratory laprotomy

Absence of conditions

associated with increased risk of

bleeding (Coagulopathy,

use of anticoagulants, cardiac failure, )

Failure rate for non operative(Adults)

GRADE 1 - 5% GRADE 2 - 10%

GRADE 3 - 20% GRADE 4 - 33%

GRADE 5 - 75%

SURGERY• operative therapy of choice is splenic conservation

where possible to avoid the risk of death from opportunistic postsplenectomy sepsis that can occur after splenectomy for trauma. However, in the presence of multiple injuries or critical instability, splenectomy is more rapid and judicious.

SPLENECTOMY

• Exploration is through a long midline incision. The abdomen is packed and explored. Exsanguinating hemorrhage and gastrointestinal soilage are controlled first

• splenic ligamentous attachments are taken down sharply or bluntly to allow for rotation of the spleen and the vasculature to the center of the abdominal wound and to identify the splenic artery and vein for ligation.

• Once the splenic artery and vein are identified and controlled by ligation,

• The gastrosplenic ligament with the short gastric vessels is divided and ligated near the spleen to avoid injury or late necrosis of the gastric wall.

• Drains are typically unnecessary unless concern exists over injury to the tail of the pancreas during operation.

SPLENORRAHPHY

• Parenchyma saving operation of spleen

• The technique is dictated by the magnitude of the splenic injury

• Nonbleeding grade I splenic injury may require no further treatment. Topical hemostatic agents, an argon beam coagulator, or electrocautery

• In grade 2 and 3 suture repair (horizontal mattress) , or mesh wrap of capsular defects. Suture repair in adults often requires Teflon pledgets to avoid tearing of the splenic capsule

PARTIAL SPLENECTOMY

• Grade IV to V splenic injury may require anatomic resection, including ligation of the lobar artery.

AUTO TRANSPLANTATION

• implanting multiple 1-mm slices of the spleen in the omentum after splenectomy.

• This technique remains experimental ,role controversial

POST OPERATIVE CARE• Recurrent bleeding in the case of

splenorrhaphy or new bleeding from missed or inadequately ligated vascular structures should be considered in the first 24-48 hours.

• Immunizations against Pneumococcus species as a routine of postoperative management.(24 hours -2 weeks)

• Some centers also routinely vaccinate for Haemophilus and Meningococcus species

COMPLICATIONS

Early:

• Bleeding• Acute gastric

distension• Gastric necrosis• Rebleeding from

splenic bed• Pancreatitis• Subphrenic abscess

Late :

• OPSI (1-6 WEEKS)

• DVT

DVT FOLLOWING SPLENECTOMY

• Splenectomy thrombocytosis ( platelets)

increases risk of DVT

• Portal vein thrombosis

• Abd pain, anorexia, thrombocytosis

• CT with IV contrast

• Prevention of DVT

• Sequential compression devises on legs

• Subcutaneous heparin

Opportunistic Post Splenectomy Infection (OPSI)

• 3% of splenectomy patients

• Higher mortality in children (especially thalassemia and SS)

• Decreased since use of pneumococcal vaccine

• Pneumonia or meningitis in half the cases

• Very rapid onset of symptoms and signs

• More than half die within 2 days of admission

• Within 2 years of splenectomy, especially children

Single daily dose of penicllin or amoxicillin for 2 yrs

FOLLOW UP OF POST SPLENECTOMY PATIENTS

• revaccination with pneumococcal vaccine after 4-5 years one time only.

• Patients should be warned about the increased risk of postsplenectomy sepsis and should consider lifelong antibiotic prophylaxis for invasive medical procedures and dental work.

• Notify their doctor immediately of any acute febrile illness

• Seek prompt treatment even after minor dog bite or other animal bite.

LIVER INJURY• The liver is the largest solid abdominal organ and is

commonly injured with abdominal trauma.

• It has a thin capsule with friable parenchyma and is found in a fixed position between bony structures, which renders it susceptible to crushing injuries.

• Its dual blood supply implies that injuries can result in significant blood loss.

• The right lobe is larger than the left and is more frequently injured.

• Segments 6, 7 and 8 are involved in 85% of injuries, commonly due to compression against the fixed ribs, spine and posterior abdominal wall.

• Given their pliable ribs and a weaker parenchymal connective tissue network, children are more susceptible to blunt liver injury.

DIAGNOSIS OF LIVER INJURY

• Focused assessment sonography in trauma (FAST) performed in the emergency room by an experienced operator can reliably diagnose free intraperitoneal fluid.

• Patients with free intraperitoneal fluid on FAST and haemodynamic instability, and

• patients with a penetrating wound will require a laparotomy and/or thoracotomy once active resuscitation is under way.

CT Grading of liver trauma is based on the American Association for the Surgery of Trauma (AAST)

injury scale

Management according to the Grade

Grade I,II

---minor injuries, represent 80-90% of all injuries, require minimal or no operative treatment

Grade III-V

-- severe,require surgical intervention

Grade VI

--incompatible with survival

Non-Operative Management of Liver Injury

• An absolute increase in the incidence of non operatively managed liver injuries (NOMLI) is unequivocal.

• Multiple studies have shown that NOMLI is effective

Criteria for NOMLI

• No indications for laparotomy (physical examination signs/symptoms or other injuries)

• Hemodynamically normal after resuscitation with crystalloid

• No injuries that preclude physical examination of the abdomen (e.g., CHI, spinal cord injury)

• No transfusion requirements (PRBC)

• Constant availability of surgical and critical care resources

COMPLICATIONS OF NOMLI

• Biliary (bile peritonitis, bile leak, biloma, hemobelia..)

• Infection (liver abscess, necrosis, abdominal sepsis, SIRs)

• Abdominal compartment syndrome 

• Hemorrhage

• Hepatic necrosis &/or Acalculous Cholecystitis

FAILURE OF NOMLI

• Usually attributed to reasons unrelated to liver injury

• Other injuries can be missed in a blunt trauma victims, such as:

• Bowel

• Pancreas

• Diaphragm

• Bladder

Which can lead to failure of NOMLI

OPERATIVE MANAGEMENT

INDICATIONS

BLUNT TRAUMA

• Hemodynamic instability

• Transfusion> 2 blood volume or > 40 ml/kg

• Devitalized parenchyma

• Sepsis / biloma

PENETRATING TRAUMA

• Exploratory lapratomy is indicated in any penetrating trauma in with peritoneal penetration

OPERATIVE INTERVENTIONS • Initial control of bleeding achieved with

temporary tamponade using packs, portal triad occlusion(Pringle manoeuvre), bimanual compression of the liver or even manual compression abdominal aorta above celiac trunk

• If hemorrhage is unaffected by portal triad occlusion(Pringle manoeuvre) by digital compression or vascular clamp, major vena cava injury or atypical vascular anatomy should be expected

Perihepatic packing

--Indication: coagulopathy, irreversible shock from blood loss (10u), hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries

HEPATOTOMY WITH DIRECT SUTURE LIGATION

• using the finger fracture technique, electrocautery or an ultrasonic dissector to expose damaged vessels and hepatic duct which ligated , clipped or repaired

• low incidence of rebleeding, necrosis and sepsis

• effectives following blunt liver trauma requires further evaluation

RESECTION DEBRIDEMENT

• removal devitalized tissue

• rapid compared with standard anatomical resection, which are more time consuming and remove more normal liver parenchyma

• reduced risk of post-op sepsis secondary hemorrhage and bile leakage

MESH WRAPPING

• --new technique for grade III,IV laceration, tamponading large intrahepatic hematomas

• --not indicated where juxtacaval or hepatic vein injury is suspected

• Anatomical resection

• --reserved for deep laceration involving major vessels or bile ducts, extensive devascularization and major hepatic venous bleeding

OTHER OPERATIVE INTERVENTIONS

• Omental packing

• Intrahepatic tamponade with penrose drains

• Fibrin glue

• Retrohepatic venous injuries --Complete Vascular isolation of the liver --venovenous bypass --Atriocaval shunting

• Liver transplantation

COMPLICATIONS

--Hemorrhage,sepsis

--Biliary fistula

--Respiratory problems

--Liver failure

--Hyperpyrexia

--Acalculous cholecystitis

--Pancreatic, duodenal or small bowel fistula

RENAL TRAUMA

The kidney is injured in approximately 10% of all

significant blunt abdominal trauma.

Of those, 13% are sports-related when the kidney, followed by

testicle, is most frequently involved.

However, the most frequent cause by far is motor vehicle accident

followed by falls

Renal lacerations and renal vascular injuries make up only 10-

15% of all blunt renal injuries. Isolated renal artery injury

following blunt abdominal trauma is extremely rare, and accounts for

less than 0.1% of all trauma patients

DIAGNOSIS AND INITIAL EMERGENCY ASSESSMENT

• Initial assessment of the trauma patient should include securing the airway, controlling external bleeding, and resuscitation of shock.

• In many cases, physical examination is carried out during the stabilisation of the patient.

• Pre-existing renal abnormality makes renal injury more likely following trauma.

The following findings on physical examination could

indicate possible renal involvement:

• haematuria;

• flank pain;• flank

ecchymoses;• flank

abrasions;

• fractured ribs;

• abdominal distension;

• abdominal mass;

• abdominal tenderness.

INDICATION FOR FURTHER IMAGING

Gross haematuria

Microscopic haematuria with haemodynamic

instability

Persistant microscopic haematuria

CT WITH INTRAVENOUS CONTRAST

Gold standard

Immediate and delayed post

contrast images to view

collecting system

Allows diagnosis and

staging

Images abdomen and retroperitone

um

Not for haemodynam

ic unstable patients

INTRAVENOUS PYELOGRAPHY

Unable to evaluate

abdomen and retroperitoneum

Inadequate for grading renal

injury

Used in unstable pat prior to surgery to

identify functioning

contralateral kidney

RENAL ANGIOGRAPHY

Delineates vascular injury (intimal tears,

pseudoaneurysm, AV fistulas)

Use when CT equivocal and

continued haemorrhage

Use for endo vascular repair (embolization,

stenting)

RENAL ULTRASOUND

Evaluation of abd/pelvic injury/fluid

acclumation

High false neg rate for renal

injury

Used in areas without CT or for follow up

AAST renal injury grading scale

NON-OPERATIVE MANAGEMENT OF RENAL INJURIES

All grade 1 and 2 renal injuries can be managed non-operatively, whether due to blunt or penetrating trauma.

Therapy of grade 3 injuries has been controversial, but recent studies support expectant treatment

Patients diagnosed with urinary extravasation in solitary injuries can be managed without major intervention and a resolution rate of > 90%.In stable patients, supportive care with bed-rest, hydration,antibiotics & continuous monitoring of vital signs until haematuria resolves is the preferred initial approach.

The failure of conservative therapy is low (1.1%)

SURGICAL MANAGEMENT

- haemodynamic instability;

- exploration for associated injuries;

- expanding or pulsatile peri-renal haematoma identified during laparotomy;

- grade 5 injury.

-pre-existing renal pathology requiring surgical therapy

OPERATIVE FINDINGS AND RECONSTRUCTION

The goal of renal exploration is control of haemorrhage and renal salvage.

the transperitoneal approach for surgery as access to the renal vascular pedicle is then obtained through the posterior parietal peritoneum, which is incised over the aorta, just medial to the inferior mesenteric vein.

Temporary vascular occlusion before opening Gerota’s fascia is a safe and effective method during exploration and renal reconstruction as it tends to lower blood loss and the nephrectomy rate.

The overall rate of patients who have a nephrectomy during exploration is around 13%.

Generally in penetrating and gun shot injuries where renal reconstruction is difficult

Renal reconstruction should be attempted in cases where the primary goal of controlling haemorrhage is achieved and a sufficient amount of renal parenchyma is viable.

Renorrhaphy is the most common reconstructive technique.

Partial nephrectomy is required when non-viable tissue is detected.

Watertight closure of the collecting system, if open, might be desirable, although some experts merely close the parenchyma over the injured collecting system with good results.

If the renal capsule is not preserved, an omental pedicle flap or peri-renal fat bolster may be used for coverage .

In all cases, drainage of the ipsilateral retroperitoneum is recommended to provide an outlet for any temporary leakage of urine.

Renovascular injuries are uncommon.

Non-operative management for segmental renal artery injury results in excellent outcomes

Following blunt trauma, repair of grade 5 vascular injury is seldom if ever effective.

Repair could be attempted in which there is a solitary kidney or the patient has sustained bilateral injuries. In all other cases, nephrectomy appears to be the treatment of choice.

Angiography with selective renal embolisation for haemorrhage control is a reasonable alternative to laparotomy provided that no other indication for immediate surgery exists

The complication rate is minimal.

Effective for grade 4 injuries where conservative therapy failed.

FOLLOW UPRepeat imaging within 2-4 days of significant renal.Within 3 months of major renal injury, patients’ follow-up should involve:

1. physical examination;

2. urinalysis;

3. individualised radiological investigation;

4. serial blood pressure measurement;

5. serum determination of renal function

COMPLICATIONSEARLY ( < 1

MONTH)

BLEEDING.

INFECTION

PERI-NEPHRIC ABSCESS

SEPSIS

URINARY FISTULA

HYPERTENSION

URINARY EXTRAVASATION

URINOMA

DELAYED

BLEEDING

HYDRONEPHROSIS

CALCULUS FORMATION

CHRONIC PYELONEPHRITIS

HYPERTENSION

ARTERIOVENOUS FISTULA

HYDRONEPHROSIS

PSEUDOANEURYSMS.

PANCREATIC INJURY• Pancreatic injuries caused by blunt trauma is exceedingly

rare (incidence 0.2‐12%)

• Clinical and laboratory findings are nonspecific

• Early diagnosis is critical in reducing morbidity and mortality

• Main pancreatic duct disruption is the greatest predictor for complications.

• Mortality rates in blunt pancreatic injury range from 10% to 30%.

• Most deaths occur within the first 48 hours due to acute haemorrhage of traumatized vasculature including:

- splenic vein

- portal vein

- inferior vena cava

MECHANISM OF INJURY

• Blunt pancreatic injury occurs with compression of pancreas between the vertebral column and anterior abdominal wall.

Adults – motor vehicle accidents

Adolescents –bicycle handlebar injuries

Infants –child abuse

• Pancreatic injury is more common in children and young adults because of decreased protective intra‐abdominal fat

DIAGNOSIS

SERUM AMYLASE

LEVEL

Suggest only pancreatic injury

Cannot predict or correlate with the degree of injury

SERUM LIPASE LEVEL

nonspecific and a poor indication of

injury

elevated levels may provide a

clue to a severe injury requiring

further investigation

ULTRASOUND

diagnosis of free

abdominal fluid or gross damage to the liver or

spleen can be done

The pancreas is not easily identified

pancreatic injuries,

parenchymal or ductal, are

frequently missed.

diagnosis of an other

intra-abdominal injury and

need for an urgent

explorative laparotomy can be done

MULTI‐DETECTOR CT

imaging modality of choice in patients

with blunt abdominal trauma

excellent initial evaluation for the

detection and characterization of solid visceral organ

injury

The sensitivity for pancreatic injury is between 67%‐85%

Pancreatic injuries tend to be subtle,

particularly within the first 12 hours after the traumatic event

MDCT provides improved evaluation of pancreatic duct

integrity, which is of the utmost

importance in triaging patients with

pancreatic injury

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRA

PHY

high sensitivity and specificity

Non invasive detection or exclusion of

pancreatic duct trauma and pancreatic specific

complications

Unable to provide real-time visualization of ductal findings and

extravasation

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

sensitivity and specificity of 100%

demonstrate clearly the site of duct disruption and the grade of duct

injury

effective and safe non-operative treatment tool

leakages of the pancreatic duct, trans

papillary stent insertion might seal the injury and

stabilize it

TREATMENT ALGORITHM

NONOPERATIVE

MANAGEMENT

absence of a ductal injury

(grade I and II)

consists of bowel

arrest, total parental nutrition

serial imaging

with either CT scans or ultrasound to follow

injury resolution

PROXIMAL DUCT INJURY

Incomplete / complete disruption of the MPD

without duct obstruction is the best

candidate for the pancreatic duct stent

therapy

Transductal pancreatic stent allows internal

drainage of the pancreatic secretion and re-establishment

of duct continuity

GRADE IV INJURIES WITH PDI

In stable patients, pancreaticoduodene

ctomy is the best definite treatment

In unstable patients, exploration and

placing of external drainage may be the

best choice for damage control

DISTAL PANCREATIC INJURY WITH DUCT INVOLVEMENT

wounds in the body or tail of the pancreas with an obvious duct injury or transection of more than half the width of the pancreas

these grade III injuries are best treated by distal pancreatectomy

complete transection of the pancreatic body from the head, a distal Pancreaticojejunostomy and closure of the proximal end of the pancreas rupture

COMPLICATIONS

fistula

pancreatic

abscess

pseudocyst

formation

sepsis

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