Pancreatic injury should be suspected in all polytrauma patients or in patients with history of any high-risk mechanism of injury. Children are more susceptible to pancreatic injury because of the minimal protective retroperitoneal fat mantle unlike adults. Hence concomitant injuries of adjacent organs are not uncommon in blunt pancreatic trauma and should be actively sought for while analysing CT scans.
Similarly right sided forces injure the head or uncinate process of pancreas along with liver, gall bladder and duodenum. A slightly left-sided force of impact directed at left upper quadrant causes injury to distal pancreas along with spleen, left kidney and stomach. Injury occurs due to the anteroposterior force compressing the pancreas against the spine with injury most commonly occurring just left to the mesenteric vessels at the junction of neck and body. Other mechanisms include fall of heavy objects over abdomen, fall from height and direct blunt assault to abdomen. The common mechanisms of blunt pancreatic trauma are motor vehicle accidents (steering wheel and seat-belt impact injuries) in adults and impact due to bicycle handlebar injuries in children. This article provides a review of pancreatic injury and discusses the mechanisms of injury, clinical and laboratory diagnosis, classification, imaging techniques, management, outcome and complications of blunt pancreatic trauma. Recently, with emphasis on early detection of ductal injury and an increasing trend towards non-operative management of low-grade pancreatic injuries, magnetic resonance imaging (MRI), encoscopic retrograde cholangio-pancreatography (ERCP) and endoscopic stenting have also been incorporated into pancreatic trauma management protocols. Computed tomography (CT) remains the mainstay for diagnosis of pancreatic trauma. In an acute setting, pancreatic injury produces severe physiologic dysfunction and traumatic pancreatitis chiefly due to leakage of enzymes from pancreatic ductal injury while in the chronic setting, duct injury leads to pseudocyst and pancreatic fistula formation. While the deep retroperitoneal location of pancreas protects it from less severe trauma, it also renders diagnosis of injury more difficult. Despite its relatively uncommon incidence, diagnosis and management of pancreatic trauma remains a persistent challenge and generates continuous debate and search for new paradigms in trauma literature. Pancreatic trauma in blunt trauma abdomen is an uncommon injury with an incidence of 2%-5%. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography.
Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Early detection of pancreatic trauma is essential to prevent subsequent complications.
In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality.