1. The Diagnosis and Management of Traumatic Pancreatic Duct Injury
SJ Co, CJ Yong-Hing, S Galea-Soler, DJ Hou, A Eftekhari, Buckley AR, L Louis, S Nicolaou
Department of Radiology, Vancouver General Hospital, University of British Columbia
INTRODUCTION
Blunt pancreatic injury is relatively uncommon but associated with high morbidity [1-2]. Poor outcomes are due to delay in recognition of ductal injury because of absence of specific symptoms, minimal physical findings, and nonspecific laboratory findings [3-4]. The absence symptoms may be due to the pancreas’ retroperitoneal location and possibly due to transient decrease in pancreatic secretions immediately after trauma which leads to minimal pancreatic inflammation and edema [5]. Delay in diagnosis can result in grave complications, such as pseudocysts, necrotizing pancreatitis, pancreatic fistula, abscess, bleeding, persistent pancreatic pain, and even death [6-8]. The broad spectrum of injuries complicates management of each case. Although surgical intervention is often warranted, less invasive alternatives, such as endoscopic retrograde cholangiopancreatography (ERCP) stent placement, percutaneous drainage, and conservative measures, are very effective treatment options depending on the severity of injury [9-11].
FIGURE 3: CLASSIFICATION OF INJURY
American Association for the Surgery of Trauma (AAST)
Grade III Injury Cont.
On axial CT (A) the pancreatic duct is poorly visible in a patient with hepatic and splenic lacerations. Axial and coronal MR (B) and (C) reveal high signal that extends through the duct just to the left of the SMV and is consistent with pancreatic laceration involving the duct. A B C
Images by Michael Liston
Non-contiguous axial CT images demonstrate complete pancreatic transection through the distal body. A B A B
Grade I
Grade II
Grade III
Grade IV
Grade V
Grade
Description I
Hematoma
Minor contusion without duct injury
Laceration
Superficial laceration without duct injury II
Major contusion without duct injury or tissue loss
Major laceration without duct injury or tissue loss
III
Transection or parenchymal injury with duct injury to the left of the SMV IV
Transection or parenchymal injury to the right of SMV V
Massive disruption of pancreatic head
ERCP images of two patients with grade 3 injuries. Abrupt termination of contrast in the distal pancreatic duct can be appreciated in the first patient (arrow) (A). ERCP images show contrast extravasation from the mid to distal pancreatic duct in the second patient (B-C). A B
Figure 1: Intraoperative photos following pancreatic trauma of (A) pancreatic neck injury and (B) pancreatic laceration associated with jejunal tear and rupture of Ligament of Treitz.
Grade IV Injury
On axial CT (A) transection is visible through the pancreatic tail (arrow). Duct involvement is confirmed on axial MR (arrowhead) (B). On follow-up axial MR (C) the laceration has resolved but a large pseudocyst has developed. A B C
ROLE OF IMAGING
The status of the main pancreatic duct (MPD) is paramount in predicting morbidity and guiding treatment [12-14]. The American Association for the Surgery of Trauma (AAST) classifies pancreatic injuries based on location of the injury with respect to the duct, the superior mesenteric vein (SMV) and evidence of duct involvement (Figure 1). Imaging modalities that can accurately localize pancreatic injury with respect to the SMV and identify duct involvement guide management.
CURRENT IMAGING MODALITIES
MDCT
Multidetector CT (MDCT) has revolutionized the quality and accuracy of CT scans [15] and has significantly improved pancreatic imaging. The course of the pancreatic duct is visualized and can thus provide important information for assessing pancreatic injury and disease [16-19]. With these improvements in accuracy, some groups are beginning to question the necessity of invasive ERCP and MRCP as diagnostic steps in the investigation of blunt pancreatic trauma [20].
ERCP 
Endoscopic retrograde cholangiopancreatography (ERCP) provides detailed images of the pancreatic duct and clearly defines the nature of the injury [13, 21]. The site of duct disruption and the grade of injury can be ascertained [10]. However, ERCP is invasive and there are associated complications so it is now reserved for those cases in which pancreatic injury is equivocal on MDCT or when the imaging and clinical findings are discordant.
MRCP
While magnetic resonance cholangiopancreatography (MRCP) is used in the assessment of chronic duct disease, it has little role in the acute trauma setting [22].
Contiguous axial CT images demonstrate transection of the pancreatic head (arrows). A B
FIGURE 2: PANCREATIC TRAUMA IMAGING ALGORITHM A B C
ERCP images with abrupt termination of the contrast column at the proximal main pancreatic duct (arrow) with contrast extravasation (arrowhead).
All Stable Patients With Blunt Abdominal Trauma
Axial (A) and coronal (B) CT show complete transection of the head of the pancreas. A B A B
Enhanced MDCT
MDCT Evidence of pancreatic injury
Equivocal on MDCT or
discordant clinical findings
Non-contiguous axial CT images show two transections of the pancreatic body (arrows).
Confident on MDCT
Grade V Injury
Axial (A) and coronal (B) CT show traumatic pancreatic pseudocyst anterior and inferior to the head of the pancreas (arrows). A B
Repeat MDCT
ERCP or MRCP
BLUNT PANCREATIC INJURY: A PICTORIAL REVIEW
Non-contiguous axial CT images with massive disruption (arrowheads) of the pancreatic head and an adjacent fluid collection in the anterior pararenal space (arrows). A B
Axial CT in 3 patients with pancreatic contusion. (A) Irregularity of pancreatic tail and stranding in the anterior pararenal space. (B) Enlargement of the pancreatic tail with adjacent stranding in a patient with hepatic laceration. (C) Stranding around the pancreatic head.
Grade I Injury A B C
Axial CT with pancreatic head enlargement and stranding in the anterior pararenal space consistent with pancreatic contusion.
Grade II Injury
AAST Grade of pancreatic injury
No evidence of MPD injury
Evidence of MPD injury
MPD injury to left of SMV
MPD injury to right of SMV
Grade I or II
CONCLUSION
MDCT plays a major role in assessing patients with pancreatic injuries.  MDCT accurately localizes the injury with respect to the duct and identifies evidence of duct involvement, which allow accurate classification and subsequently guides management.  Understanding radiographic classification of traumatic pancreatic injuries is helpful in patient triage. Our pancreatic trauma imaging algorithm demonstrates how imaging findings are integrated with clinical findings to determine which patients require invasive intervention.
Conservative
management
Grade III
No massive disruption of pancreatic head
Massive disruption of pancreatic head
Grade III Injury
Distal pancreatectomy
+/- Splenectomy
Axial (A) and (C) and coronal (B) CT with pancreatic tail transection (arrow) with peripancreatic and free intraperitoneal fluid (arrowhead). A B C
Grade IV
Grade V
REFERENCES
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Pancreatic duct stent
(Whipple)
Whipple