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SOLID ORGAN INJURIES

FOLLOWING ABDOMINAL
TRAUMA
MODERATORS – 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


CRUSHING abdomen

• Sudden decelerations apply a shearing force


across organs with fixed attachments
SHEARING

• Raised intraluminal pressure by abdominal


BURSTING compression accurately in hollow organs can
lead to rupture

• Disruption of bony areas by blunt trauma may


PENETRATION generate bony spicules that can cause
secondary penetrating injury
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

FIRST PRIORITIES Accordingly,


Whether the PROTOCOL : resuscitation and
patient is • Brief clinical management of
haemodynamically examination to shock by
evaluate ABC along
• maintenance of ABC
-stable with cardiovascular
• IV fluids
status with blood
-unstable • nasogastric tube insertion
pressure and pulse
• Catheterization
measurement
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
laparotomy

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
DIAGNOSTIC
FOUR PERITONEAL
QUADRANT LAVAGE
TAP:
Criteria for positive
tap –

Overall accuracy
– about 90% Gross bloody tap

>1,00,000 RBCs per


Positive tap – mm
obtaining 0.1 ml
or more of non > 500 white blood cells
clotting blood per mm

Negative tap
does not rule Elevated amylase level
out
haemorrhage
Presence of bile or
bacteria or faeces
ULTRASOUND
FAST EXAMINATIONS (focused assessment
with sonography for trauma).
ADVANTAGES

Differentiates
Inexpensive,
pulseless electrical
noninvasive and
activity from extreme
portable
hypotension

Performed by
emergency
Serial examination
physicians and
can detect ongoing
surgeons trained in
hemorrhage
performing FAST
examinations.

Confirms presence of
hemoperitoneum in
minutes Avoids risks associated
•Deceases time to laparotomy
with contrast media
•Great adjunct during multiple
casualty disasters
DISADVANTAGES

A minimum of 70 ml
Sensitivity – 69%- of intraperitoneal
99% fluid for positive
study.

Accuracy is
dependent on
Sensitivity is low for operator /
small-bowel and interpreter skill and
pancreatic injury is decreased with
prior abdominal
surgery.

Technically difficult
Does not define exact
with – obese, ileus or
cause of
subcutaenous
hemoperitoneum
emphysema is present
Technique -
Four basic transducer positions used
to find abdominal fluid.
ABDOMINAL CT SCAN

-Latest generation of
helical and multislice
-Criterion standard for
scanners provides rapid
solid organ injuries.
and accurate
diagnostic information.

-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 DISADVANTAGES:

extent of organ injuries and determines


the need for laparotomy pneumoperitoneum may
Defines which intraabdominal injuries
elevate ICP
may be safely managed nonsurgically

More sensitive than DPL or CT in


uncovering -
General anesthesia
• Diaphragmatic injuries usually necessary
• Hollow viscus injuries

Surgery can be done in same sitting


Patient must be
• With laparoscope with minimal trauma hemodynamically stable
• Open surgery
LAPAROTOMY
Pneumoperitoneum or
pneumoretroperitoneum
Peritonitis (gross blood, bile
or faeces)
Evidence of diaphragmatic
defect

INDICATIONS

Gross blood from stomach


or rectum Positive diagnostic test for
an injury requiring operative
Abdominal distension with repair
hypotension
SPLENIC INJURY
The spleen is the intra-abdominal organ most
frequently injured in blunt trauma
Spleen lies in posterior portion of lt upper quadrant,
deep to ninth ,tenth and eleven ribs
Convex 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 supply


Arises 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
GASTROSPLENIC SPLENORENAL

SPLENOPHRENIC SPLENORENAL

These ligaments are


avascular except
Provide attachment
gastrosplenic
of spleen with
ligament (containing
adjacent structures
short gastric and
gastroepiploic artery)
Patient may
present with the
upper abdominal or
flank pain

May present with Referred


tachycardia pain to the
,Tachypnea, anxiety , shoulder
Hypotension (shock)
(kehr sign)

PRESENTATION

Pt may have signs


of lt upper quadrant
tenderness or signs
Some may be
of generalized asymptomatic
peritoneal irritation.

Physical examination
is insensitive and non
specific.
Organ Injury Scaling-American
Association of the Surgery of Trauma
(OIS-AAST)
MANAGEMENT

Nonoperative management of
splenic injury is successful in >90% Non operative management
of children, irrespective of the successful in adults 65%
grade of splenic injury.

blunt trauma patient with evidence


of hemodynamic instability
unstable patients suspected of
unresponsive to fluid challenge with
splenic injury and intra-abdominal
no other signs of external
hemorrhage should undergo
hemorrhage should be considered
exploratory laparotomy and splenic
to have a life-threatening solid
repair or removal.
organ (splenic) injury until proven
otherwise.
FLOWCHART FOR MANAGEMENT
Haemodynamic
stability

Absence of conditions
associated with
increased risk of Negative
bleeding abdominal
(Coagulopathy, use of Criteria for
anticoagulants, non
scan
cardiac failure, )
operative
management

Absence of other Absence of


clear indications contrast
for exploratory extravasation on
laprotomy CT

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: Late :
• Bleeding
• Acute gastric distension
• OPSI (1-6 WEEKS)
• Gastric necrosis • DVT
• Rebleeding from splenic
bed
• Pancreatitis
• Subphrenic abscess
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 PENETRATING TRAUMA
• Hemodynamic instability • Exploratory lapratomy is
indicated in any penetrating
• Transfusion> 2 blood volume or
trauma in with peritoneal
> 40 ml/kg
penetration
• Devitalized parenchyma
• Sepsis / biloma
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:

• abdominal
• haematuria;
tenderness.

• flank pain;
• abdominal • flank
mass; ecchymoses;
• flank abrasions;

• abdominal
• fractured ribs;
distension;
INDICATION FOR FURTHER IMAGING

Gross haematuria

Microscopic
haematuria with
haemodynamic
instability

Persistant
microscopic
haematuria
CT WITH INTRAVENOUS
CONTRAST

Immediate and
delayed post
Allows diagnosis
Gold standard contrast images to
view collecting and staging
system

Images Not for


abdomen and haemodynamic
retroperitoneum unstable patients
INTRAVENOUS PYELOGRAPHY

Unable to evaluate
Inadequate for
abdomen and
grading renal injury
retroperitoneum

Used in unstable pat


prior to surgery to
identify functioning
contralateral kidney
RENAL ANGIOGRAPHY

Delineates vascular Use when CT


injury (intimal tears, equivocal and
pseudoaneurysm, continued
AV fistulas) haemorrhage

Use for endo


vascular repair
(embolization,
stenting)
RENAL ULTRASOUND
Evaluation of
abd/pelvic High false neg rate
injury/fluid for renal injury
acclumation

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 UP
Repeat 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


COMPLICATIONS
EARLY ( < 1 MONTH) DELAYED

BLEEDING. BLEEDING

INFECTION HYDRONEPHROSIS

PERI-NEPHRIC ABSCESS CALCULUS FORMATION

CHRONIC
SEPSIS PYELONEPHRITIS

URINARY FISTULA HYPERTENSION

HYPERTENSION ARTERIOVENOUS FISTULA

URINARY
HYDRONEPHROSIS
EXTRAVASATION

URINOMA 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
SERUM LIPASE
AMYLASE
LEVEL
LEVEL

nonspecific and a
Suggest only poor indication of
pancreatic injury
injury

elevated levels may


Cannot predict or provide a clue to a
correlate with the severe injury
degree of injury requiring further
investigation
ULTRASOUND

diagnosis of free
abdominal fluid
The pancreas is
or gross damage
not easily
to the liver or
identified
spleen can be
done

diagnosis of an
pancreatic other intra-
injuries, abdominal injury
parenchymal or and need for an
ductal, are urgent
frequently explorative
missed. laparotomy can
be done
MULTI‐DETECTOR CT
excellent initial evaluation
imaging modality of
for the detection and
choice in patients with
characterization of solid
blunt abdominal trauma
visceral organ injury

Pancreatic injuries tend to


The sensitivity for
be subtle, particularly
pancreatic injury is
within the first 12 hours
between 67%‐85%
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
CHOLANGIOPANCREATOGRAPHY

Non invasive detection or


high sensitivity and exclusion of pancreatic duct
specificity trauma and pancreatic
specific complications

Unable to provide real-time


visualization of ductal
findings and extravasation
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

demonstrate clearly the site of


sensitivity and specificity of
duct disruption and the grade
100%
of duct injury

leakages of the pancreatic


effective and safe non- duct, trans papillary stent
operative treatment tool insertion might seal the injury
and stabilize it
TREATMENT ALGORITHM
absence of a
ductal injury
(grade I and II)

NONOPER
ATIVE
MANAGE
MENT
serial imaging
with either CT consists of
scans or bowel arrest,
ultrasound to total parental
follow injury nutrition
resolution
GRADE IV
PROXIMAL
INJURIES WITH
DUCT INJURY
PDI

Incomplete / complete
disruption of the MPD In stable patients,
without duct obstruction is pancreaticoduodenectomy
the best candidate for the is the best definite
pancreatic duct stent treatment
therapy

Transductal pancreatic
In unstable patients,
stent allows internal
exploration and placing of
drainage of the pancreatic
external drainage may be
secretion and re-
the best choice for damage
establishment of duct
control
continuity
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
fistula

pancrea
COMPLICATIO
sepsis NS tic
abscess

pseudocyst
formation