Abstract
Pancreatic injury after blunt abdominal trauma is exceedingly uncommon, occurring in less than 5 % of major abdominal injuries. When blunt pancreatic injury does occur, however, it is notoriously difficult to identify. The use of serum amylase has been advocated in the diagnosis of such injury, yet it is neither sensitive nor specific. Computed tomography has become widely accepted in the evaluation of hemodynamically stable patients after blunt abdominal trauma, although it is clearly not a sensitive modality for the detection of pancreatic injury. In fact, numerous examples of normal CT scans with missed pancreatic injury have been documented. However, careful attention to CT technique and awareness of the CT manifestations of pancreatic injury may facilitate the diagnosis of pancreatic injury. Additionally, important information about the pancreatic duct can be obtained with the use of MRI-pancreatography or endoscopic retrograde pancreatography. Accurate, timely identification of major pancreatic ductal injury is imperative because delay in diagnosis and associated vascular injuries are largely responsible for the high morbidity and mortality associated with blunt pancreatic trauma. Blunt pancreatic trauma can be managed successfully by means of both operative and selective approaches.
Similar content being viewed by others
References
Timberlake GA. Blunt pancreatic trauma: Experience at a rural referral center. Am Surg 1997;63:282–286.
Jones WG, Reilly DM, Barie PS. Pancreatic injuries. AORNJ 1991;53:917–933.
Jurkovich GJ, Carrico CJ. Pancreatic trauma. Surg Clin North Am 1990;70:575–593.
Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF, Malangoni MA. Pancreatic trauma: A ten-year multi-institutional experience. Am Surg 1997;63:598–604.
Akhrass R, Kim K, Brandt C. Computed tomography: An unreliable indicator of pancreatic trauma. Am Surg 1996;62:647–651.
Northrup WF III, Simmons RL. Pancreatic trauma. A review. Surgery 1972;71:27–43.
Jones RC. Management of pancreatic trauma. Am J Surg 1985;150:698–704.
Wilson RF, Tagett JP, Pucelik JP, Walt AJ. Pancreatic trauma. J Trauma 1967;7:643–651.
Davis JJ, Cohn I, Nance FC. Diagnosis and treatment of blunt abdominal trauma. Ann Surg 1976;183:672–678.
Bach RD, Frey CF. Diagnosis and treatment of pancreatic trauma. AmJ Surg 1971;121:20–29.
Donovan AJ, Turrill F, Berne CJ. Injuries of the pancreas from blunt trauma. Surg Clin North Am 1972;52:649–665.
Jones RC, Shires GT. Pancreatic trauma. Arch Surg 1971; 102:424–430.
Jeffrey RB Jr, Federle MP, Crass RA. Computed tomography of pancreatic trauma. Radiology 1983;147:491–494.
Wolfman NT, Bechtold RE, Scharling ES, Meredith JH. Blunt upper abdominal trauma: Evaluation by CT. AJR 1992;158:493–501.
Patton JH, Lyden SP, Croce MA, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Pancreatic trauma: A simplified management guideline. J Trauma 1997;43:234–239.
Dodds WJ, Taylor AJ, Erickson SJ, Lawson TL. Traumatic fracture of the pancreas: CT characteristics. J Comput Assist Tomogr 1990;14:375–378.
Lewis G, Kridge JEJ, Bornman PC, Terblanche J. Traumatic pancreatic pseudocyst. Br J Surg 1993;80:89–93.
Haapiaienen RA, Kiluto T, Lempinen M. Pancreatic trauma: Acute and late manifestations. Br J Surg 1988;75:165–167.
Horst HM, Bivins BA. Pancreatic transection. A concept of evolving injury. Arch Surg 1989;124:1093–1095.
Barkin JS, Ferstenberg RM, Panullo W, Manten HD, Davis RCJr. Endoscopic retrograde cholangiopancreatography in pancreatic trauma. Gastrointest Endosc 1988;34:102–105.
Jurkovich GJ. The duodenum and pancreas. In Mattox KL, Feliciano DV, Moore EE, eds. Trauma, 4th ed. New York: McGraw-Hill, 2000, pp 735–762.
Lucas CE. Diagnosis and treatment of pancreatic and duodenal injury. Surg Clin North Am 1977;57:49–65.
Cogbill TH, Moore EE, KashukJL. Changing trends in the management of pancreatic trauma. Arch Surg 1982;117:722–728.
Smego DR, Richardson JD, Flint LM. Determinants of outcome in pancreatic trauma. J Trauma 1985;25:771–776.
Wisner DH, Wold RL, Frey CF. Diagnosis and treatment of pancreatic injuries. Arch Surg 1990;125:1 109–1113.
Bradley EJ m, Young PR Jr, Chang MC, Allen JE, Baker CC, Meredith W, Reed L, Thomason M. Diagnosis and initial management of blunt pancreatic trauma: Guidelines from a multi-institutional review. Ann Surg 1998;227:861–869.
Stone HH, Fabian TC, Satiani B, Turkleson ML. Experience in the management of pancreatic trauma. J Trauma 1981;21:257–262.
Craig MH, Talton DS, Hauser CJ, Poole GV. Pancreatic injuries from blunt trauma. Am Surg 1995;61:125–128.
Nelson MG, Jones DR, Vasilakis A, Timberlake GA. Computed tomographic diagnosis of acute blunt pancreatic transection. West VaMedJ 1994;90:274–278.
Leppaniemi A, Haapiainen R, Kiviluto T, Lempinen M. Pancreatic trauma: Acute and late manifestations. Br J Surg 1988;75:165–167.
Karl HW, Chandler JG. Mortality and morbidity of pancreatic injury. Am J Surg 1997;134:549–554.
Cogbill TH, Moore EE, Morris JA Jr, Hoyt DB, Jurkovich GJ, Mucha P Jr, Ross SE, Feliciano DV, Shackford SR. Distal pancreatectomy for trauma: a multicenter experience. J Trauma 1991;31:1600–1606.
Graham JL, Mattox KL, Jordan G. Traumatic injuries of the pancreas. Am J Surg 1978;136:744–748.
Balasegaram M. Surgical management of pancreatic trauma. Curr Probl Surg 1979;16:1–59.
Sims EH, Mandal AK, Schlater T, Fleming AW, Lou MA. Factors affecting outcome in pancreatic trauma. J Trauma 1984;24:125–128.
Cook DE, Walsh JW, Vick CW, Brewer WH. Upper abdominal trauma: Pitfalls in CT diagnosis. Radiology 1986; 159:65–69.
Wilson RH, Moorehead RJ. Current management of trauma to the pancreas. Br J Surg 1991;78:1196–1202.
Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Schackford SR, Trafton PG. Organ injury scaling. II. Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990;30:1427–1428.
Naffziger HC, McCorkle JH. The recognition and management of acute trauma to the pancreas, with particular reference to the use of the serum and lab test. Ann Surg 1943;118:594–602.
Olsen WR. The serum amylase in blunt abdominal trauma. J Trauma 1973;13:200–204.
Boulanger BR, Milzman DP, Rosati C, Rodriquez A. The clinical significance of acute hyperamylasemia after blunt trauma. CanJ Surg 1993;36:63–69.
Moretz JA, Campbell DP, Parker DE, Williams GR. Significance of serum amylase level in evaluating pancreatic trauma. AmJ Surg 1975;130:739–741.
Fabian TC, Kudsk KA, Croce MA, Payne LW, Mangiante EC, Voeller GR, Britt LG. Superiority of closed suction drainage for pancreatic trauma: A randomized prospective study. Ann Surg 1990;211:724–728.
Bouwman DL, Weaver DW, Walt AJ. Serum amylase and its isoenzymes: A clarification of their implications in trauma. J Trauma 1984;24:573–578.
Jobst MA, Canthy TG, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 1999;34:818–824.
Hall RI, Lavelle MI, Venables CW. Use of ERCP to identify the site of traumatic injuries of the main pancreatic duct in children. BrJ Surg 1986;73:411–412.
Takehara Y. Can MRCP replace ERCP? J Magn Reson Imaging 1998;8:517–534.
Soto JA, Yucel EK, Barish MA, Chuttani R, Ferrucci JT. MR cholangiopancreatography after unsuccessful or incomplete ERCP. Radiology 1996;199:91–98.
Greenlee T, Murphy K, Ram MD. Amylase isoenzymes in the evaluation of trauma patients. Am Surg 1984;50:637–640.
Dolich MO, McKenney MG, Varela E, Compton RP, McKenney KL, Cohn SM. 2,576 ultrasounds for blunt abdominal trauma. J Trauma 2001;50:108–112.
Glaser K, Tschmelitsch J, Klingler P, Wetscher G, Bodner E. Ultrasonography in the management of blunt abdominal and thoracic trauma. Arch Surg 1994; 129:743–747.
Gruessner R, Mentges B, Duber C, Ruckert K, Rothmund M. Sonography versus peritoneal lavage in blunt abdominal trauma. J Trauma 1989;9:242–244.
Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: Lessons learned from 1540 patients. Ann Surg 1998;228:557–567.
Shackford SR, Rogers FB, Osler TM, Trabulsy ME, Clauss DW, Vane DW. Focused abdominal sonogram for trauma: The learning curve of nonradiologist clinicians in detecting hemoperitoneum. J Trauma 1999;46:553- 562.
Thomas B, Falcone RE, Vasquez D, Santanello S, Townsend M, Hockenberry S, Innes J, Wanamaker S. Ultrasound evaluation of blunt abdominal trauma: Program implementation, initial experience, and learning curve. J Trauma 1997;42:384–390.
Yoshii H, Sato M, Yamamoto S, Motegi M, Okusawa S, Kitano M, Nagashima A, Doi M, Takuma K, Kato K, Aikawa N. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998; 45:45–51.
Sivit CJ, EichelbergerMR, Taylor GA, Bulas DI, Gotschall CS, Kushner DC. Blunt pancreatic trauma in children: CT diagnosis. AJR 1992;158:1097–1100.
Rubio PA, Cichoso C. Traumatic transection of the pancreas with subsequent chronic pancreatitis. South Med J 1987;80:272–273.
Wong YC, Wang LJ, Lin BC, Chen CJ, Lim KE, Chen RJ. CT grading of blunt pancreatic injuries: Prediction of ductal disruption and surgical correlation. J Comput Assist Tomogr 1997;21:246–250.
Sivit CJ, Eichelberger MR. CT diagnosis of pancreatic injury in children: Significance of fluid separating the splenic vein and the pancreas. AJR 1995;165:921–924.
Lane MJ, Mindelzun RE, SandhuJS, McCormick VD, Jeffrey RB. CT diagnosis of blunt pancreatic trauma: Importance of detecting fluid between the pancreas and the splenic vein. AJR 1994;163:833–835.
Peitzman AB, Makaroun MS, Blasky BS, Ritter P. Prospective study of CT in initial management of blunt trauma. Trauma 1986;26:585–591.
Keogan MT, Baker ME. Computed tomography and magnetic resonance imaging in the assessment of pancreatic disease. Gastrointest Endosc Clin N Am 1995;5:31–59.
Mirvis SE, Shanmuganathan K. Trauma radiology: Part I. Computerized tomographic imaging of abdominal trauma. J Intensive Care Med 1994;9:151–163.
Udekwu DO, Gurkin B, Oller DW. The use of computed tomography in blunt abdominal injuries. Am Surg 1996;62:56–59.
Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children: Mechanism of injury. J Trauma 1997;42:49–53.
West OC, Jarolinek AM. Abdomen: Traumatic emergencies. In Harris JH Jr, Harris WH, eds. The Radiology of Emergency Medicine, 2nd ed. Philadelphia: Lippincott-Williams & Wilkins, 2000, pp 708–710.
Wyatt SH, Fishman EK. Spiral CT of the pancreas. Semin Ultrasound CTMR 1994;15:122–132.
Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP). Gastroenterology 1976;70:314–320.
Stone A, Sugawa C, Lucas C, Hayward S, Nakamura R. The role of endoscopic retrograde pancreatography (ERP) in blunt abdominal trauma. Am Surg 1990;56:715–720.
Nirula R, Velmahos GC, Demetriades D. Magnetic resonance cholangiopancreatography in pancreatic trauma: A new diagnostic modality? J Trauma 1999;47:585–587.
Fabre JM, Bauret P, Prudhomme M, Quenet F, Noel P, Baumel H, Domergue J. Posttraumatic pancreatic fistula cured by endoprosthesis in the pancreatic duct. Am J Gastroenterol 1995;90:804–806.
Huckfeldt R, Agee C, Nichols WK, Barthel J. Nonoperative treatment of pancreatic duct disruption using an endoscopically placed stent. J Trauma 1996;41:143–144.
Fulcher AS, Turner MA, Yelon JA, McClain LC, Broderick T, Ivatury RR, Sugerman HJ. Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: Preliminary findings. J Trauma 2000;48:1001–1007.
Jeffrey RB, Laing FC, Wing VW. Ultrasound in acute pancreatic trauma. Gastrointest Radiol 1986; 11:44–46.
Berni GA, Bandyk DR, Oreskovich MR, Carrico CJ. Role of intraoperative pancreatography in patients with injury to the pancreas. Am J Surg 1982;143:602–605.
Kimble RM, Cohen R, Williams S. Successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a child. J Pediatr Surg 1999;34:1518–1520.
Koniaris LG, Mandel AK, Genuit T, Cameron JL. Twostage trauma pancreaticoduodenectomy: Delay facilitates anastomotic reconstruction. J GASTROINTEST SURG 2000;4:366–369.
Agostino HB, van Sonnenberg E, Sanchez RB, Goodacre BW, Villaveiran RG, Lyche K. Treatment of pancreatic pseudocyst with percutaneous drainage and octreotide. Work in progress. Radiology 1993;187:685–688.
Warshaw AL, Rattner DW, Fernandez-del Castillo C, Z’graggen K. Middle segment pancreatectomy: A novel technique for conserving pancreatic tissue. Arch Surg 1998;133:327–331.
Gentilello LM, Cortes V, Buechter KJ, Gomez GA, Castro M, Zeppa R. Whipple procedure for trauma. Is duct ligation a safe alternative to pancreaticojejunostomy? J Trauma 1991;31:661–668.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Cirillo, R.L., Koniaris, L.G. Detecting blunt pancreatic injuries. J Gastrointest Surg 6, 587–598 (2002). https://doi.org/10.1016/S1091-255X(01)00028-2
Issue Date:
DOI: https://doi.org/10.1016/S1091-255X(01)00028-2