RobGordonBUSM2010

BethIsraelDeaconessMedicalCenter
Dr.GillianLieberman

Presentationoverview
y Anindexpatientpresentation
y Overviewofpancreaticinjuryinblunt
abdominaltrauma
y TheroleofmultirowdetectorCTimaging
y Companionpatientswithimagingfindings
suggestiveofpancreaticinjury
y Companionpatientsdemonstratingimaging
pitfalls
y Outcomeforourindexpatient
y AcknowledgementsandReferences

Ourindexpatient:
y A49yearoldmalewhowasanunrestraineddriverin
amotorvehiclecollision
y Hehadlossofconsciousness,difficultybreathing and
diffuseabdominalpaininthefield
y Cool,paleanddiaphoreticonarrivaltoER.
y BPin thefieldinthe90swithHRinthe70s
y Significantlabvalues:Amylase142,Lipase62,
creatinine 1.2,Hemoglobin10andHematocrit 28.

CTimagefindingsforourpatient:

Axial contrast enhanced CT

images demonstrating
hypoattenuating fluid
between the splenic vein
and posterior border of the
pancreas (blue arrow).
All images courtesy of BMC PACS

Axial contrast enhanced CT

images with free fluid
surrounding the liver (blue star)
and peripancreatic fluid.

Amoreconcerningfindinginourindex
patientisapossiblepancreaticlaceration
Axial contrast enhanced
CT image that shows an
hypoattenuating linear
lesion (blue arrow)
through the pancreas.
This lesion extends
through >50% of the
parenchyma.

Image courtesy of BMC PACS

Somebackgroundonpancreatic
injuriesinbluntabdominaltrauma:
y Pancreaticinjuriescausedby
blunttraumaisexceedingly
rare(incidence0.212%)
y Clinicalandlaboratory
findingsarenonspecific
y Earlydiagnosisiscriticalin
reducingmorbidityand
mortality
y Mainpancreaticduct
disruptionisthegreatest
predictorforcomplications. http://www.nativeremedies.com/images/design/ailmentPhotoPancreas.jpg

MechanismofPancreaticInjury
Bluntpancreaticinjury
occurswithcompressionof
pancreasbetweenthe
vertebralcolumnand
anteriorabdominalwall.

Adults motorvehicle
accidents
Adolescents bicycle
handlebarinjuries
Infants childabuse

y Pancreaticinjuryismore
commoninchildrenand
youngadultsbecauseof
decreasedprotectiveintra
abdominalfat

http://www.radiologyassistant.nl/images/thmb_43ce5595362a9abdom-trauma-child-abuse.jpg

Companionpatient#1:
Mortalityinpancreatictrauma
y Mortalityratesinblunt
pancreaticinjuryrange
from10%to30%
y Mostdeathsoccurwithin
thefirst48hoursdueto
acutehemorrhageof
traumatizedvasculature
including:
y splenicvein
Axial contrast enhanced CT image
y portalvein
demonstrating transection of pancreatic
y inferiorvenacava
head and body with active extravasation of
contrast fluid (arrow heads).
Gupta et al. Radiology 2004)

Left: Companion patient 2: Axial contrast

enhanced CT image with a loculated fluid
collection (*) representing a pseudocyst.
Gupta et al. Radiographics 2004.

Right: Companion patient 3: Axial

contrast enhanced CT image in a patient
6 days after trauma showing expanding
fluid collections within the pancreas.
Gupta et al. Radiographics 2004.

DiagnosingPancreaticinjury:
TheRoleofMultidetectorCT.
Computedtomographyistheimagingmodalityofchoice
inpatientswithbluntabdominaltrauma
CTprovidesanexcellentinitialevaluationforthe
detectionandcharacterizationofsolidvisceralorgan
injury
Thesensitivityforpancreaticinjuryisbetween67%85%
(mainlybasedonsingledetectorCT)
Pancreaticinjuriestendtobesubtle,particularlywithin
thefirst12hoursafterthetraumaticevent
MDCTprovidesimprovedevaluationofpancreaticduct
integrity,whichisoftheutmostimportanceintriaging
patientswithpancreaticinjury

CTimagingfindingssuggestiveof
pancreaticinjury:
y
y
y
y
y

Peripancreaticfluidcollections
Hyperattenuation/Activeextravasation
Contusion/Pancreaticenlargement
Pancreatichematoma
Laceration/Fracture

CompanionPatient#4and#5:Superficial
Lacerationswithoutductalinvolvement

Below: Companion patient 5: Axial

contrast enhanced CT image with
superficial laceration through the tail of
the pancreas. Laparotomy confirmed
the pancreatic duct remained intact.
Gupta et al. Radiographics 2004

Above: Companion patient 4: Axial contrast

enhanced image showing a linear
hypoattenuating line through <50% of the
pancreas. Note depth of laceration <50%
corresponds with decreased chance of main
pancreatic duct involvement.
Rekhi et al. Emergency Radiology 2009.

Companion patient 6: Axial

contrast enhanced CT
image showing fracture of
the pancreatic tail. Ductal
involvement should be
confirmed with MRCP or
surgery.

Companion patient 7:
Axial contrast enhanced
CT image demonstrating
transection through the
pancreatic neck.

3 images from Gupta et al. Radiographics. 2004

Companion patient 8:
Axial contrast enhanced
CT image with laceration
through more than 50%
of the parenchyma.
Ductal disruption was
confirmed at surgery.

Companionpatient#9:
PeripancreaticfluidCollections
y Axialcontrastenhanced
CTimagewithsignificant
peripancreaticandintra
abdominalfluid
collections.Peripancreatic
fluidisaverysensitivebut
nonspecificimaging
findinginpancreatic
trauma.Fluidiscommonly
foundbetweenthesplenic
veinandinferiorborderof
thepancrea.

Image courtesy of BMC PACS

2AxialcontrastenhancedCT
imageswithhematoma
surroundingthepancreas.
Pancreatichematomapresent
asareasofheterogenous
attenuationwithinor
surroundingtheparenchyma.
Activelybleedinghematoma
willnotshowwashouton
delayedphaseimaging

2 images from Rekhi et al. Emergency Radiology 2009

Below: Companion patient 12:

Delayed phase image showing
sustained hyperattenuation indicative
of active hemorrhage.
Rekhi et al. Emergency Radiology 2009.

Above: Companion patient 11: Axial

portal venous phase image showing
multiple areas of active contrast
extravasation.
Image courtesy of BMC PACS

Companion patient 13:

Axial contrast enhanced
CT image with focal
area of relative
hypoattenuation within
the neck of the normally
enhancing parenchyma
indicative of pancreatic
contusion.

Companion patient 14:

Axial contrast enhanced
CT image with area of
hypoattenuation within
the body of the
pancreas.

Companion patient 15:

Axial contrast enhanced CT
image with area of
hypoattenuation within the
head of the pancreas.
Associated with relative
engorgement of the
surrounding parenchyma.

Rekhi et al. Emergency Radiology 2009

Rekhi et al. Emergency Radiology 2009

Image courtesy of BMC PACS

Inherentcharacteristicsofpancreatic
injuriesthatcancausedefectstobemissed:
y Thereareanumberofcharacteristicsofpancreaticinjuriesthatleadto

bothfalsepositiveandfalsenegativeresultsonCTimaging.
y Injuriescanoftenbesubtleandrequireboththekeeneyeofthe
radiologistandtheclinicalsuspicionofthesurgicalteam.
Reasonsforfalsenegatives:
y Obscuredfractureplanes
y Surroundinghemorrhage
y Closeappositionofpancreaticfragments
y Associatedinjuries satisfactionofsearch
***manyofthesechangeswillpresentonfollowupexams***
y

Reasonsforfalsepositives:
y Peripancreaticfluidafteraggressivefluidresuscitation
y Peripancreaticfluidfromanalternativesource
y Atrophicorfattypancreas
y Pancreaticclefts

CompanionPatient#16:Diagnostic
difficultiesinPancreatictrauma:
y Giventhehighimpact
mechanisms,pancreatic
injuryrarelyoccursin
isolation.Pancreatic
injuriesmaybeobscured
byassociatedinjuries.
y

Associatedinjuriestotheliver,
spleen,duodenumandkidneys,
occurin90%ofevents

y Serumenzymesareneither
sensitivenotspecific
y

Initialserumamylase/lipaselevels
normalin40%

Axial contrast enhanced CT

image with splenic and right
adrenal hematoma in a patient
with full transection of the tail of
the pancreas.
Rekhi et al. Emergency Radiology 2009.

Companionpatient#17:SourcesofFluidinthe
PararenalSpacewithoutPancreaticinjury:
Aggressivefluidresuscitation
Hypovolemicshockcomplex
Blooddissectingfroman

intraperitonealviscusinjury
Fluidtravelingviathesplenorenal
ligamentafterinjurytothesplenic
hilum
Fluidtravelingthoroughdirect
extensionwithinjurytothebarearea
oftheliver
Bloodorbowelcontentsfromduodenal
injuryandblood
Urinedissectingfromarenalinjury
Axial contrast enhanced CT image with
followingdisruptionoftheposterior
significant peripancreatic fluid after
renalfascia
aggressive fluid resuscitation. The patient
was treated conservatively without
pancreatic complications.
Rekhi et al. Emergency Radiology 2009.

Companionpatient#18:Asymmetricfatty
AtrophyofthePancreas Nottobeconfused
withpancreaticcontusion!
Coronal(above)andaxial
(below)contrastenhanced
CTimagesofapatient
withareasof
hypoattenuationcausedby
separationofthe
parenchymabyintermixed
fat.Thisnormalvariant
seeninobeseandelderly
patientsmaybe
misinterpretedas
pancreaticcontusionsor
fractures.
2 Images courtesy of BMC PACS.

Companionpatient#19:PancreaticClefts
Nottobeconfusedforpancreaticlacerations!
Coronal(above)andaxial(below)
contrastenhancedCTimagesofa
patientwithmultiplelinear
hypoattenuatinglesionswiththe
pancreascreatedbyfatthat
surroundsarterialandvenous
vesselsthatpenetratethepancreas.
Thisisanormalvariantthatmaybe
misdiagnosedasfractures
Images courtesy of BMC PACS

Our patient was taken to the OR for emergent

laparotomy. Findings included:

Retroperitoneal hematoma and edema

near and around the head of the pancreas.
No evidence of any active bleeding, but
there was some clear fluid coming from the
area.
Fracture through the tail of the pancreas
These findings were in agreement with our
imaging findings discussed at the beginning of
this presentation.

2 axial contrast enhanced images at

the level of the pancreas
2 images courtesy of BMC PACS

References
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y

Cirillo RLJr,Leonidas GK(2002)Detectingbluntpancreaticinjuries.JGastrointest Surg 6:587589.

Rekhi,S.,Anderson,S.,Rhea,J.,Soto,J.(2009).Imagingofbluntpancreatictrauma.EmergencyRadiology..
GuptaA,Stuhlfaut JW,FlemingKW,Lucey BS,SotoJA(2004)Blunttraumaofthepancreasandbiliary tract:amultimodalityimagingapproachtodiagnosis.Radiographics
24:13811395.
Jurkovich GJ(2000)Theduodenumandpancreas.In:MattoxKL,FelicianoDV,MooreEE(eds)Trauma,4thedn.McGrawHill,NewYork,NY,pp735762
WongYC,WangLJ,LinBC,ChenCJ,LimKE,ChenRJ.CTgradingofbluntpancreaticinjuries:predictionofductaldisruptionand surgicalcorrelation.JComput Assist
Tomogr 1997;21:246250.
FischerJH,CarpenterKD,OKeefeGE.CTdiagnosisofanisolatedbluntpancreaticinjury.AJRAmJRoentgenol 1996;167:1152.
Ilahi O,Bochicchio GV,Scalea TM(2002)Efficacyofcomputedtomographyinthediagnosisofpancreaticinjuriesinadultblunttraumapatients:asingleinstitutionalstudy.
AmSurg 68:704708
Akhrass R,Yaffe MB,BrandtCPetal(1997)Pancreatictrauma:atenyearmultiinstitutionalexperience.AmSurg 63:598604
Madida TE,Mokoena TR(1995)Favorableprognosisaftersurgicaldrainageofgunshot,staborblunttraumaofthepancreas.BrJSurg 82:12361239.
LinBC,ChenRJ,FangJFetal(2004)Managementofbluntmajorpancreaticinjury.JTrauma56:774778
WolfA,BernhardtJ,Patrzyk Metal(2005)Thevalueofendoscopicdiagnosisandthetreatmentofpancreasinjuriesfollowingbluntabdominaltrauma.Surg Endosc 19:665
669
Tyburski JG,DenteCJ,WilsonRFetal(2001)Infectiouscomplicationsfollowingduodenaland/orpancreatictrauma.AmSurg 67:227231
BradleyEL3rd,YoungPRJr,ChangMC,etal.Diagnosisandinitialmanagementofbluntpancreatictrauma:guidelinesfromamultiinstitutionalreview.AnnSurg 1998;
227:861 869.
DawsonAR,WebsterCH,HoweHC,Theron EJ,Meiring L.Ruptureoftheheadofthepancreasbyblunttrauma:acasereport.SAfr MedJ1985;67:560562.
JonesRC.Managementofpancreatictrauma.AmJSurg 1985;150:698704.
DavisJJ,CohnI,NanceFC.Diagnosisandtreatmentofbluntabdominaltrauma.AnnSurg 1976;183:672678.
LucasCE.Diagnosisandtreatmentofpancreaticandduodenalinjury.Surg Clin NorthAm1977;57:4965.
Cogbill TH,MooreEE,Kashuk JL.Changingtrendsinthemanagementofpancreatictrauma.ArchSurg 1982;117:722728.
Smego DR,RichardsonJD,FlintLM.Determinantsofoutcomeinpancreatictrauma.JTrauma1985;25:771776.
WisnerDH,Wold RL,FreyCF.Diagnosisandtreatmentofpancreaticinjuries.ArchSurg 1990;125:11091113.
WilsonRH,Moorehead RJ.Currentmanagementoftraumatothepancreas.BrJSurg 1991;78:11961202.

References
y
y
y
y
y
y
y

Jurkovich GJ,Carrico CJ.Pancreatictrauma.Surg Clin NorthAm1990;70:575593.

Northrup WFIII,SimmonsRL.Pancreatictrauma.Areview.Surgery1972;71:2743.
BachRD,FreyCF.Diagnosisandtreatmentofpancreatictrauma.AmJSurg 1971;121:2029.
DonovanAJ,Turrill F,BerneCJ.Injuriesofthepancreasfromblunttrauma.Surg Clin NorthAm1972;52:649665.
RyanS,SandlerA,Trenhaile Setal(1994)Pancreaticenzymeelevationsafterblunttrauma. Surgery116:622627
LaneMJ,Mindelnuz RE,JeffreyRB(1996)Diagnosisofpancreaticinjuryafterbluntabdominaltrauma.Semin UltrasoundCTMR17:177182
JeffreyRBJr,Federle MP,CrassRA.Computedtomographyofpancreatictrauma.Radiology1983;147:491494.

Acknowledgements
y Dr.StephanAnderson,BMC
y Dr.GillianLieberman,BIDMC