Thread by @samrad77

Traumatic pancreatic injuries are difficult to diagnose on imaging. This timely and comprehensive review article by Ayoob et al. in the latest issue of @RadioGraphics- addresses multimodality imaging of pancreatic trauma.

1/19

#RGphx
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@CookyScan

Pancreatic injuries are frequently overlooked on initial CT due to the low frequency of these injuries, associated nonspecific clinical features, and relatively subtle imaging findings, and the presence of associated multiple organ injuries.

2/19 #RGphx

In a patient with abdominal organ injuries on CT, how frequently is a pancreatic injury associated?

3/19 #RGphx

Answer: Pancreatic injuries occur in 10% of those with other abdominal injuries. 2% of all trauma patients have pancreatic injuries. It is not as uncommon as one might think.

4/19 #RGphx

Multiphasic Contrast-enhanced CT (arterial and venous phase) is the initial imaging modality of choice for evaluating the pancreas following abdominal trauma in a hemodynamically stable patient.

5/19 #RGphx

MRCP and/or ERCP serves as a problem-solving modality in hemodynamically stable patients for whom there is no immediate indication for laparotomy, to assess MPD integrity.

6/19 #RGphx

Which imaging features on trauma CT are surrogate markers of possible pancreatic injury?
1. Fluid in the anterior pararenal space
2. Duodenal wall hematoma
3. High grade splenic or liver injury
4. Burst-chance fracture of the spine
5. All of the above

#7/19 #RGphx

Answer: All of the above.
Any retroperitoneal organ injury, fluid in the anterior pararenal space, unstable spine fracture, or high-grade liver-spleen injury- are associated with possible pancreatic injury

#8/19 #RGphx

In the setting of trauma, fluid/hemorrhage in the anterior pararenal space; haziness of the regional fat or fluid between the pancreatic parenchyma and splenic vein or features of seat-belt injury- should raise suspicion for pancreatic injury.
9/19 #RGphx

Direct signs of pancreatic injury at CT include laceration, focal pancreatic enlargement, and pancreatic hematoma.

Indirect CT signs include peripancreatic fluid, induration of the peripancreatic fat, and thickening of the left anterior renal fascia.

10/19 #RGphx

For standard communication with trauma surgeons, radiologists should use the AAST-OIS classification system (five grades). The type (contusion, laceration, transection) and location (proximal versus distal) of the injury is used to assign an AAST-OIS grade.

11/19 #RGphx

The key distinction between low-grade (AAST-OIS grades I and II) and high-grade (AAST-OIS grades III–V) pancreatic injuries is the involvement of the MPD.

12/19 #RGphx

Injury involving the proximal (right to the PV-SMV axis) pancreas has a worse overall course and prognosis compared to the distal pancreatic injury (to the left of the PV-SMV axis).

13/19 #RGphx

Which imaging findings suggest the MPD injury?

1. Pancreatic fistula, pseudocyst, or abscess formation
2. Pancreatic laceration on either side of MPD on any of the planes
3. Laceration extending more than 50% of the depth of the pancreas
4. All of the above

14/19 #RGphx

Answer: All of the above. The integrity of the Main Pancreatic duct (MPD) is the major determinant of patient outcome. MRI with MRCP is complementary to CT in non-invasive assessment of MPD integrity.
#15/19 #RGphx

Management of pancreatic injuries depends on multiple factors, including AAST-OIS injury grade, hemodynamic status of the patient, and extent of associated organ damage.

16/19 #RGphx

Low-grade (grades I and II) pancreatic injuries are typically managed non-surgically, whereas high-grade (grades III–V) injuries may require resection with possible reconstruction and/or drainage procedures.

17/19 #RGphx

In summary, a systematic search pattern with knowledge of direct and indirect signs of pancreatic trauma on imaging is essential. Multiphasic CT is the imaging modality of choice. MRI with MRCP is complementary to CT in diagnosing MPD injury.

18/19 #RGphx

The critical roles of the radiologist in the management of pancreatic trauma are 1. To identify the injury 2. To grade the injury 3. To determine MPD integrity.

Share your experience of diagnosing pancreatic injury!

19/19 #RGphx

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