Pancreatic Trauma (Pancreas Injury)

What is Pancreatic Trauma (Pancreas Injury)?

“Eat when you can, sleep when you can, and don’t touch the pancreas” is a longstanding piece of advice in the surgical world. But what happens if the pancreas gets damaged? Damage to the pancreas is a rare, but potentially serious injury that can be very hard to identify. Unlike organs like the liver, kidney or spleen, regular imaging techniques like X-rays or they might not pick up on minor signs of pancreas injury. Inflammation of the pancreas due to trauma may not show changes in blood or swelling for several hours after the initial injury.

Often, more specialized imaging tests such as magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) might be needed. Delay in spotting and diagnosing pancreas injury can lead to severe problems such as infection, pseudocysts, abscess, narrowing of the duct, peritonitis, and hormone or digestive problems, which can be associated with high health risks and chances of death. Misunderstanding the severity of the injury can interfere with proper treatment. A high level of awareness and extensive knowledge is needed to spot, categorize, and effectively treat pancreas injury. This is a brief summary to help further provide care for patients with pancreas injuries.

What Causes Pancreatic Trauma (Pancreas Injury)?

Traumatic pancreatic injury typically happens as a result of a sharp or penetrating wound. Certain blunt traumas can also cause it; for instance, children might get hurt by a bicycle handlebar, adults can be injured by a steering wheel during a car crash, or someone might get a direct kick in an assault. These cause a sudden forceful impact on the stomach, pressing the internal organs against the spine and potentially damaging the pancreas.

It’s crucial to identify if the main pancreatic duct is disrupted, as it is the primary source of delayed complications. It’s worth noting that pancreatic injuries rarely happen alone, with 90% of the cases often involving damage to another abdominal organ. The most common is the combined injury of the duodenum and the pancreas.

Risk Factors and Frequency for Pancreatic Trauma (Pancreas Injury)

Pancreatic injury, which is an injury to the pancreas, is rare and makes up for a small 0.2% to 1.1% of all trauma-related injuries. The majority of these injuries, about 63%, are caused by sharp items such as gunshots or stabs. The rest, or the remaining 37%, come from blunt trauma to the abdomen, like a fall or accident.

In terms of abdominal trauma injuries, pancreatic injuries make up a low 3% to 12%. In all types of trauma, including head injuries, bone fractures, etc., pancreatic injuries account for an even lower percentage of 0.2% to 2%.

Deaths caused by pancreatic injuries have a range between 9% and 34%. In hospitals specialized for high-level trauma care (known as level 1 trauma centers), up to 64% of patients experience health complications.

Fewer cases, just a mere 30%, involve injuries to the pancreas only, without other organs being affected. Among these particular cases, only 5% result in tragic fatalities. Finally, it’s worth noting that injuries to the pancreas caused by blunt force are more common in children than adults, likely because their bodies have less fat to protect their organs.

Signs and Symptoms of Pancreatic Trauma (Pancreas Injury)

Traumatic pancreatitis is a medical condition that can be challenging to diagnose and requires careful investigation. Damage to the pancreas is relatively rare and it’s seldom the only part of the body affected. Diagnosing this type of injury can be complex because pancreatic injuries often occur with other abdominal damages due to its location at the back of the abdomen. Symptoms like severe stomach pain that radiates to the back, nausea, and vomiting are common, similar to other nearby organs that might be injured. The standard abdominal examination may not always succeed in diagnosing this condition, as it can give false negative results 34% of the time on initial checking. Because these signs and symptoms aren’t specific to pancreatic damage, doctors need to be highly vigilant to avoid missing the diagnosis.

Testing for Pancreatic Trauma (Pancreas Injury)

Diagnosing an injury to the pancreas can be incredibly challenging, and often, the injury isn’t noticed until serious complications occur. Standard lab tests are not typically much help, either. For instance, even if the pancreas is severely damaged or split apart, blood tests looking at pancreatic enzymes like lipase and amylase might still show normal results in about a third of patients. These enzymes can also be elevated due to injuries to other parts of the body or alcohol intoxication, making it even harder to use them to pinpoint a pancreatic injury.

Imaging techniques like ultrasound and X-ray play a vital role in assessing trauma. X-rays are useful if there’s a need to look for foreign objects in the body, such as in cases of penetrating injuries. Ultrasound scans are widely accessible and quick, but they may not always pick up on acute pancreas damage. They can, however, help identify conditions that are complications of the injury, like a pseudocyst.

Computed tomography or CT scans are the preferred test for patients with non-severe blunt abdominal injury but even these can struggle to identify pancreatic injuries. In fact, within the first 12 hours after trauma, CT scans may look normal in 20% to 40% of cases. Some indicators of injury that could be found on a CT scan include laceration, swelling, and leaks of pancreatic fluid, among other signs. Furthermore, a CT scan is helpful in identifying very specific signs of a pancreas injury, such as fractures or separations of fragments.

Despite their uses, CT scans aren’t perfect in this context, with their ability to identify a major duct injury being as low as 43%. Given the risk of poor outcomes if a ductal injury is missed, doctors have started to increasingly use other techniques like MRCP and ERCP. MRCP, a type of specialized MRI scan, is a quick and non-invasive method that can evaluate the whole pancreatic duct system and fluid collections or disruptions. Meanwhile, ERCP is the most accurate tool for diagnosing ductal injuries and can serve as both a diagnostic and treatment tool. However, it should be used sparingly due to potential complications, including organ perforation, pancreatitis, bleeding, and infection.

Treatment Options for Pancreatic Trauma (Pancreas Injury)

Pancreatic injury can be a serious complication of trauma and can result in damage to multiple organs. The first step in treating this type of injury is to stabilize the patient’s internal blood flow and heart functionality — this focuses on stopping any bleeding and avoiding spillage of stomach fluids. The course of treatment will depend heavily on several factors such as the severity of damage to the pancreas, the location of the injury, the patient’s stability, and any other injuries that have occurred.

Initially, conservative treatments such as inserting a tube into the nose to help with suction, allowing the bowel to rest, and providing nutritional support may be implemented. However, if the main pancreatic duct is injured, treatment may involve placing a stent with the guidance of an endoscopic retrograde cholangiopancreatography (ERCP) for drainage. For injuries caused by penetrating trauma, surgical exploration of the abdomen is usually needed. Medical intervention becomes extremely crucial within 24 hours of a major pancreatic injury in patients who have suffered blunt abdominal trauma to prevent significant complications or death.

It’s important to accurately assess the injury to offer proper treatment. The American Association for the Surgery of Trauma (AAST) put forward the pancreatic Organ Injury Scale (OIS) which helps to evaluate the extent of pancreatic injury using CT scan findings. This method is primarily employed for stable patients with blunt pancreatic injury. The 2016 Eastern Association of the Surgery of Trauma (EAST) released some guidelines for treating traumatic pancreatic injury. Based on severity, injuries are categorized into low-grade (grade I or II) or high-grade (grade III to V). Low-grade injuries are managed conservatively if there’s no injury to the pancreatic duct. High-grade injuries require surgery, the type of which depends on whether the duodenum is involved. Without substantial data, it’s not clear when pancreaticoduodenectomy should be performed. Currently, the use of octreotide, a drug that controls symptoms related to some types of tumors, is not recommended for this treatment due to its unproven benefits. Likewise, there is no clear stance on whether to routinely remove the spleen during distal pancreatic resection.

The Pancreatic Injury Mortality Score (PIMS) is a scoring system to predict the risk of death from traumatic pancreatic injury. It takes into account factors like age (over 55), shock on admission, vascular injury, number of associated injuries, and the AAST pancreatic OIS. Based on the score, the risk level is sorted into low (0 to 5), medium (5 to 9), and high (9 to 20), with corresponding mortality rates of approximately less than 1%, 15%, and 50% respectively.

Sudden (acute) inflammation of the pancreas
Pancreatitis caused by gallstones
Pancreatitis that leads to bleeding
Pancreatitis causing swelling and fluid build-up in the pancreas
Destructive pancreatitis that destroys pancreatic tissue
Non-cancerous growths in the pancreas
Shrinkage of the pancreas
Indentations or abnormal “dents” in the pancreas
Cancerous growth in the pancreas that affects hormone-producing cells
Excessive fat accumulation in the pancreas
Cancerous or non-cancerous growths in the pancreas
Abnormal pancreas condition that mimics pancreatitis but isn’t

Frequently asked questions

Pancreatic trauma, or pancreas injury, is a rare but potentially serious injury that can be difficult to identify. Regular imaging techniques like X-rays may not pick up on minor signs of pancreas injury, so more specialized imaging tests such as MRCP or ERCP might be needed. Delay in spotting and diagnosing pancreas injury can lead to severe problems and high health risks.

Pancreatic trauma (pancreas injury) is rare and makes up for a small 0.2% to 1.1% of all trauma-related injuries.

Signs and symptoms of Pancreatic Trauma (Pancreas Injury) include: - Severe stomach pain that radiates to the back - Nausea - Vomiting These symptoms are common and similar to other nearby organs that might be injured. It is important to note that these signs and symptoms are not specific to pancreatic damage, which makes diagnosing this condition challenging. Doctors need to be highly vigilant to avoid missing the diagnosis, as the standard abdominal examination may not always succeed in diagnosing this condition. Additionally, the initial checking can give false negative results 34% of the time.

Pancreatic trauma or pancreas injury can occur as a result of a sharp or penetrating wound, blunt trauma to the abdomen, such as a fall or accident, or a direct forceful impact on the stomach, such as from a bicycle handlebar, a steering wheel during a car crash, or a direct kick in an assault.

The doctor needs to rule out the following conditions when diagnosing Pancreatic Trauma (Pancreas Injury): - Sudden (acute) inflammation of the pancreas - Pancreatitis caused by gallstones - Pancreatitis that leads to bleeding - Pancreatitis causing swelling and fluid build-up in the pancreas - Destructive pancreatitis that destroys pancreatic tissue - Non-cancerous growths in the pancreas - Shrinkage of the pancreas - Indentations or abnormal "dents" in the pancreas - Cancerous growth in the pancreas that affects hormone-producing cells - Excessive fat accumulation in the pancreas - Cancerous or non-cancerous growths in the pancreas - Abnormal pancreas condition that mimics pancreatitis but isn't

The types of tests that are needed for Pancreatic Trauma (Pancreas Injury) include: 1. Blood tests: These tests can look at pancreatic enzymes like lipase and amylase, although they may not always show abnormal results in cases of pancreatic injury. 2. Imaging techniques: These include ultrasound, X-ray, and CT scans. Ultrasound scans are quick and widely accessible, but they may not always detect acute pancreas damage. X-rays are useful for looking for foreign objects in the body. CT scans are the preferred test for non-severe blunt abdominal injury, but they may struggle to identify pancreatic injuries. 3. MRCP and ERCP: MRCP is a specialized MRI scan that can evaluate the whole pancreatic duct system and fluid collections or disruptions. ERCP is the most accurate tool for diagnosing ductal injuries and can also be used for treatment. 4. Pancreatic Organ Injury Scale (OIS): This is used to evaluate the extent of pancreatic injury using CT scan findings. 5. Pancreatic Injury Mortality Score (PIMS): This is a scoring system that predicts the risk of death from traumatic pancreatic injury based on factors like age, shock on admission, vascular injury, number of associated injuries, and the AAST pancreatic OIS.

The treatment for pancreatic trauma, or pancreas injury, depends on several factors such as the severity of the damage, the location of the injury, the patient's stability, and any other injuries that may have occurred. Initially, conservative treatments may be implemented, such as inserting a tube into the nose for suction, allowing the bowel to rest, and providing nutritional support. If the main pancreatic duct is injured, a stent may be placed with the guidance of an endoscopic retrograde cholangiopancreatography (ERCP) for drainage. For injuries caused by penetrating trauma, surgical exploration of the abdomen is usually necessary. Medical intervention within 24 hours of a major pancreatic injury is crucial to prevent complications or death. The treatment approach is determined by accurately assessing the injury using the pancreatic Organ Injury Scale (OIS) and considering the guidelines provided by the American Association for the Surgery of Trauma (AAST) and the Eastern Association of the Surgery of Trauma (EAST). The Pancreatic Injury Mortality Score (PIMS) is a scoring system that predicts the risk of death based on factors such as age, shock on admission, vascular injury, associated injuries, and the AAST pancreatic OIS.

The prognosis for pancreatic trauma (pancreas injury) can vary depending on the severity of the injury and the timeliness of diagnosis and treatment. However, it is important to note that pancreatic injuries can be serious and potentially life-threatening. Complications such as infection, pseudocysts, abscess, narrowing of the duct, peritonitis, and hormone or digestive problems can arise, which can increase the health risks and chances of death. In hospitals specialized for high-level trauma care, up to 64% of patients may experience health complications.

A surgeon or a specialist in trauma surgery.