eMedicine Specialties > Trauma > Abdominal Trauma

Pancreatic Trauma: Workup

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Contributor Information and Disclosures

Updated: Jun 30, 2006

Workup

Laboratory Studies

  • Blood work is notoriously unreliable when used to help diagnose blunt or penetrating trauma to the pancreas. Amylase and lipase levels may be within reference ranges, even in the presence of ductal disruption and pancreatic transection. Normal blood work findings do not guarantee or exclude pancreatic injury. Elevation in amylase levels is suggestive of pancreatic injury or inflammation but is not diagnostic. Elevated amylase levels in trauma may be from salivary glands, small bowel injury, ovarian injury, or a host of other sources. In some studies, amylase elevation was not observed until 3-4 hours after injury and, in some cases, not at all. Lipase levels are no more specific for pancreatic injury. This method has been used more frequently in children, but recent reports suggest that it may not be as cost-effective for screening pediatric pancreatic injuries as once thought.
  • Amylase detected in diagnostic peritoneal lavage (DPL) fluid is much more sensitive and specific for pancreatic injury than blood or serum amylase determinations. However, this study is not a standard or routine test in most institutions and may take significantly longer than anticipated to perform and to receive results unless previous arrangements or protocols are in effect with the diagnostic laboratory.

Imaging Studies

  • Plain films of the abdomen may show pancreatic calcification from previous episodes of pancreatitis but are rarely of any benefit in detecting blunt trauma. These films can be valuable in detecting penetrating trauma by visualizing and localizing foreign bodies such as bullet fragments and projectile-induced bony injury. Frequently, these films can be obtained simultaneously with the bony pelvis films advocated by advanced trauma life support (ATLS) protocols in trauma victims by use of a larger x-ray plate and widening of the field of x-ray exposure.
  • Kidney, ureter, bladder (KUB) film or upright abdominal films rarely provide useful information and only serve to delay the implementation of further care or diagnostic measures.
  • While not specifically useful in the detection of pancreatic trauma, the upright chest film may show free air under the diaphragm, which is suggestive of an associated gastric, duodenal, or small bowel injury and is frequently associated with pancreatic injury.
  • CT scan
    • In a patient who is hemodynamically stable, a CT scan provides the safest and most comprehensive means of diagnosis of pancreatic injury. Unfortunately, the sensitivity of this modality is reported only to be in the range of 40-68%, so patients must be monitored closely if pancreatic injury is suspected. Most reports have examined single detector or spiral scanners, but 64 detector helical scanners that are now available may provide a more accurate determination of injury. A CT scan may be augmented by the judicious use of ERCP in select cases. Laparotomy has a higher sensitivity but is not a reasonable screening test for all suspected cases of pancreatic injury.
    • A CT scan of the abdomen provides the simplest and least invasive diagnostic modality currently available to aid in the detection of a stable blunt pancreatic injury. However, this study is only rarely useful in acute penetrating injury.
    • A workup for patients who are stable and have knife wounds to the back or flank may include a CT scan, but a patient who is unstable must never be placed in the CT scanner, whether the injury is blunt or penetrating trauma.
    • CT scan is contraindicated in patients who are hemodynamically unstable or who have a penetrating trauma in which the decision for operative intervention has been made.
    • A CT scan of the pancreas is also useful in the follow-up care of patients with a pancreatic injury and trauma. Traumatic pancreatic cysts, pseudocysts, delayed ductal injury, pancreatic transection, pancreatitis, abscess, pancreatic necrosis, and splenic artery aneurysms may be noted after surgery or after the patient is released from the hospital.
  • Magnetic resonance cholangiopancreatography (MRCP) is being used more frequently in Level 1 Trauma Centers to assess injury to the ductal components but has not been prospectively compared to CT or other modalities.

Other Tests

  • Intraoperative cholangiograms and pancreatic ductograms, especially with reflux into the pancreatic ducts (eg, Wirsung, Santorini), frequently provide information regarding the status of the injured pancreas when direct visualization is not helpful. Some authors recommend that these studies be performed during operative exploration, noting that they may help decrease complications due to missed pancreatic ductal injuries.

Diagnostic Procedures

  • In the patient who is unstable, operative exploration provides the optimal diagnostic tool for pancreatic injury. As in blunt trauma, endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative dye studies may provide more information in a select patient population.
  • ERCP is increasingly being used to help diagnose, both immediately and in delayed fashion, the presence of pancreatic ductal injuries. Some authors suggest early ERCP (ie, within 6-12 h of injury) to minimize delayed complications. While extremely helpful, this procedure has potential complications that can limit its usefulness in patients with pancreatic trauma. For it to be of benefit, the endoscopist must be skilled and experienced in its use in the injured and potentially severely ill trauma patient. This is especially true when used in the operating room in a patient with an open abdomen who is at risk for hypothermia with exposed abdominal contents.

Histologic Findings

Histologic examination of the resected pancreas documents the presence of hemorrhage and, frequently, of crush injuries to the tissue. Occasionally, this examination may reveal chronic preexisting pancreatic conditions such as pancreatitis, saponification, scarring, or tumors.

Staging

Visit the American Association for the Surgery of Trauma (AAST) Web site for a published injury scoring system for pancreatic trauma that correlates to morbidity and mortality.

More on Pancreatic Trauma

Overview: Pancreatic Trauma
Workup: Pancreatic Trauma
Treatment: Pancreatic Trauma
Follow-up: Pancreatic Trauma
References
[ CLOSE WINDOW ]

References

  1. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg. Mar 2003;38(3):354-7; discussion 354-7.

  2. Akhrass R, Yaffe MB, Brandt CP. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. Jul 1997;63(7):598-604. [Medline].

  3. Asensio JA, Demetriades D, Hanpeter DE et al. Management of pancreatic injuries. Curr Probl Surg. May 1999;36(5):325-419. [Medline].

  4. Bradley EL 3rd, Young PR Jr, Chang MC. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg. Jun 1998;227(6):861-9. [Medline].

  5. Clements RH, Reisser JR. Urgent endoscopic retrograde pancreatography the stable trauma patient. Am Surg. Jun 1996;62(6):446-8. [Medline].

  6. Cohen DB, Magnotti LJ, Lu Q, et al. Pancreatic duct ligation reduces lung injury following trauma and hemorrhagic shock. Ann Surg. Nov 2004;240(5):885-91.

  7. Craig MH, Talton DS, Hauser CJ. Pancreatic injuries from blunt trauma. Am Surg. Feb 1995;61(2):125-8. [Medline].

  8. Fabian TC. Infection in penetrating abdominal trauma: risk factors and preventive antibiotics. Am Surg. Jan 2002;68(1):29-35.

  9. Farrell RJ, Krige JE, Bornman PC. Operative strategies in pancreatic trauma. Br J Surg. Jul 1996;83(7):934-7. [Medline].

  10. Firstenberg MS, Volsko TA, Sivit C. Selective management of pediatric pancreatic injuries. J Pediatr Surg. Jul 1999;34(7):1142-7. [Medline].

  11. Fischer JH, Carpenter KD, O''Keefe GE. CT diagnosis of an isolated blunt pancreatic injury. Am J Roentgenol. Nov 1996;167(5):1152. [Medline].

  12. Gorecki PJ, Cottam D, Angus LD, Shaftan GW. Diagnostic and therapeutic laparoscopy for trauma: a technique of safe and systematic exploration. Surg Laparosc Endosc Percutan Tech. Jun 2002;12(3):195-8.

  13. Graham JM, Mattox KL, Jordan GL Jr. Traumatic injuries of the pancreas. Am J Surg. Dec 1978;136(6):744-8. [Medline].

  14. Gupta A, Stuhlfaut JW, Fleming KW, et al. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. Sep-Oct 2004;24(5):1381-95. [Medline].

  15. Ilahi O, Bochicchio GV, Scalea TM. Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study. Am Surg. Aug 2002;68(8):704-7; discussion 707-8.

  16. Jones RC. Management of pancreatic trauma. Am J Surg. Dec 1985;150(6):698-704. [Medline].

  17. Kealey WD, Garstin WI, Diamond T. Transection of the pancreatic head following blunt abdominal trauma. Br J Clin Pract. May-Jun 1995;49(3):158-9. [Medline].

  18. Kouchi K, Tanabe M, Yoshida H. Nonoperative management of blunt pancreatic injury in childhood. J Pediatr Surg. Nov 1999;34(11):1736-9. [Medline].

  19. Leppaniemi AK, Haapiainen RK. Risk factors of delayed diagnosis of pancreatic trauma. Eur J Surg. Dec 1999;165(12):1134-7. [Medline].

  20. Madiba TE, Mokoena TR. Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas. Br J Surg. Sep 1995;82(9):1236-9. [Medline].

  21. Mayer JM, Tomczak R, Rau B, et al. Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome. Dig Surg. 2002;19(4):291-7; discussion 297-9.

  22. McGahren ED, Magnuson D, Schaller RT. Management of transected pancreas in children. Aust N Z J Surg. Apr 1995;65(4):242-6. [Medline].

  23. Nwariaku FE, Terracina A, Mileski WJ et al. Is octreotide beneficial following pancreatic injury?. Am J Surg. Dec 1995;170(6):582-5. [Medline].

  24. Olah A, Issekutz A, Haulik L, Makay R. Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management. Dig Surg. 2003;20(5):408-14.

  25. Patton JH Jr, Lyden SP, Croce MA. Pancreatic trauma: a simplified management guideline. J Trauma. Aug 1997;43(2):234-9; discussion 239-41. [Medline].

  26. Procacci C, Graziani R, Bicego E. Blunt pancreatic trauma. Role of CT. Acta Radiol. Jul 1997;38(4 Pt 1):543-9. [Medline].

  27. Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR. Apr 2004;25(2):180-204.

  28. Smith DR, Stanley RJ, Rue LW 3rd. Delayed diagnosis of pancreatic transection after blunt abdominal trauma. J Trauma. Jun 1996;40(6):1009-13. [Medline].

  29. Takishima T, Sugimoto K, Hirata M. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg. Jul 1997;226(1):70-6. [Medline].

  30. Timberlake GA. Blunt pancreatic trauma: experience at a rural referral center. Am Surg. Mar 1997;63(3):282-6. [Medline].

  31. Tyburski JG, Dente CJ, Wilson RF, et al. Infectious complications following duodenal and/or pancreatic trauma. Am Surg. Mar 2001;67(3):227-30; discussion 230-1.

  32. Vasquez JC, Coimbra R, Hoyt DB, Fortlage D. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury. Dec 2001;32(10):753-9.

  33. Wind P, Tiret E, Cunningham C. Contribution of endoscopic retrograde pancreatography in management of complications following distal pancreatic trauma. Am Surg. Aug 1999;65(8):777-83. [Medline].

  34. Wolf A, Bernhardt J, Patrzyk M, Heidecke CD. The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma. Surg Endosc. May 2005;19(5):665-9.

  35. Wong YC, Wang LJ, Lin BC. CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation. J Comput Assist Tomogr. Mar-Apr 1997;21(2):246-50. [Medline].

  36. Wright MJ, Stanski C. Blunt pancreatic trauma: a difficult injury. South Med J. Apr 2000;93(4):383-5. [Medline].

  37. Young PR Jr, Meredith JW, Baker CC. Pancreatic injuries resulting from penetrating trauma: a multi- institution review. Am Surg. Sep 1998;64(9):838-43; discussion 843-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

abdominal trauma, penetrating trauma, retroperitoneal trauma, blunt trauma, pancreatic injury, gunshot wound, GSW, multiple organ injury, impalement, pancreatitis, diabetes mellitus, Whipple procedure, pancreatic duodenectomy, endoscopic retrograde cholangiopancreatography, ERCP, pancreaticojejunostomy, acute respiratory distress syndrome, ARDS, multisystem organ failure

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern
Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other; AMGEN Consulting fee Consulting

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.