Pancreatic Trauma Workup

Updated: Jan 27, 2015
  • Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Workup

Laboratory Studies

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  • 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.
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Imaging Studies

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  • 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. [4] 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. [5]
  • 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.
  • An evaluation of the utility of multidetector CT (MDCT) with MRI correlation in patients with blunt pancreatic trauma concluded that MDCT performs well in grading pancreatic injury and evaluating pancreatic ductal injury. The study further concluded that MRI is useful in evaluation of acute pancreatic trauma as it can increase diagnostic confidence and provide more qualitative information regarding the extent of injury. [6]
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Other Tests

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  • 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.
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Diagnostic Procedures

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  • 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.
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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.

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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.

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