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Case 3816

Pancreatic fracture

Author(s)

Belo-Oliveira P, Rodrigues H, Belo-Soares P, Teixeira L

Patient

male, 22 year(s)

Clinical Summary

A twenty two year-old male patient was admitted to the emergency department following a car accident resulting in blunt abdominal trauma.

Clinical History and Imaging Procedures

A twenty two year-old male patient was admitted to the emergency department following a car accident resulting in blunt abdominal trauma. On admission he had a stable hemodynamic state, but there was severe pain in the epigastric region. Computed tomography showed the pancreas with a fracture line in the body, and an enlarged tail and fluid was present in the peri-pancreatic fat. The diagnosis of a pancreatic fracture was established.

Discussion

Blunt abdominal trauma may result in a variety of abdominal injuries. While injuries involving the liver and spleen are common and are usually detected by imaging without difficulty, pancreatic and biliary injuries may be more subtle. The pancreas, sitting in a relatively protected position high in the retro peritoneum, is frequently injured in typical blunt injuries (eg from motor vehicle crashes), compared with its splenic and hepatic counterparts. Injuries of the pancreas, gallbladder, and bile ducts due to blunt trauma are rare and difficult to detect but are associated with high morbidity and mortality, especially if diagnosis is delayed. Accurate and early diagnosis is imperative, and imaging plays a key role in detection. Knowledge of the mechanisms of injury, the types of injuries, and the roles of various imaging modalities is essential for prompt and accurate diagnosis. Injury to the pancreas is relatively uncommon, occurring in less than 2% of blunt abdominal trauma patients. The pancreas is vulnerable to crushing injury in blunt trauma due to the impact against the adjacent vertebral column. Two-thirds of pancreatic injuries occur in the pancreatic body, and the remainder occurs equally in the head, neck, and tail. Symptoms and clinical findings are often nonspecific and unreliable. The classic triad of fever, leukocytosis, and elevation of serum amylase levels is rarely encountered. CT is routinely used as first-line imaging in the acute trauma patient and can be helpful in defining injuries to the pancreas and associated complications. For blunt abdominal trauma, CT images are usually obtained in the portovenous phase, 60–70 seconds after injection of iodinated contrast media. Ideally, the section collimation is 5 mm or less, with at least a 20% overlap between adjacent reconstructed images. Direct signs of pancreatic injury include pancreatic laceration, transection, and comminution. Fluid collections, such as hematomas, pseudocysts, and abscesses, are often seen communicating with the pancreas at the site of fracture or transection. Focal enlargement of the pancreas and peripancreatic fluid is suggestive of pancreatic injury, and faint fracture lines may be seen on close inspection. Peripancreatic fat stranding, haemorrhage, and fluid between the splenic vein and pancreas are useful secondary signs. The prognosis of pancreatic injuries is primarily related to the integrity of the pancreatic duct. Therefore, any patient with pancreatic injuries at CT or with a high clinical index of suspicion should be considered for MR Cholangiopancreatography or Endoscopic retrograde pancreatogram for direct imaging of the pancreatic duct. Since delay in diagnosis increases the risk of delayed complications, MR Cholangiopancreatography should be performed promptly in all patients with suspected pancreatic injury, ideally within 24–48 hours of initial injury. If imaging of the pancreatic duct is not adequate or an injury is detected that might be amenable to stent placement, ERCP should be performed promptly. CT is also helpful for detecting delayed complications of pancreatic injury, such as abscesses, pseudo cysts, and development of fistulous tracts.

Final Diagnosis

Pancreatic fracture

MeSH

  1. Pancreatic Diseases [C06.689]

References

  1. [1]

Traumatic fracture of the pancreas: CT characteristics. Dodds WJ, Taylor AJ, Erickson SJ, Lawson TL J Comput Assist Tomogr. 1990 May-Jun;14(3):375-8

  1. [2]

Value of computed tomography in the evaluation of retroperitoneal organ injury in blunt abdominal trauma. Porter JM, Singh Y Am J Emerg Med. 1998 May;16(3):225-7

  1. [3]

Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 2: Gastrointestinal tract and retroperitoneal organs. Becker CD, Mentha G, Schmidlin F, Terrier F Eur Radiol. 1998;8(5):772-80

Citation

Belo-Oliveira P, Rodrigues H, Belo-Soares P, Teixeira L (2005, Jun 17).

Pancreatic fracture, {Online}.

URL: http://www.eurorad.org/case.php?id=3816

DOI: 10.1594/EURORAD/CASE.3816

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·  Published 17.06.2005

·  DOI 10.1594/EURORAD/CASE.3816

·  Section Gastro-Intestinal Imaging

·  Case-Type Clinical Case

·  Views 71

·  Language(s)

·  Figure 1

Abdominal CT

Axial contrast-enhanced CT scan shows a complete fracture of the pancreatic body with fluid and haemorrhage between the pancreatic fragments

·  Figure 2

Abdominal CT

Axial contrast-enhanced CT scan shows slight enlargement of the pancreatic tail with a fluid collection.

·  Figure 3

Abdominal CT

Axial contrast-enhanced CT scan shows a fluid collection at the pancreatic tail

Figure 1

Abdominal CT

Axial contrast-enhanced CT scan shows a complete fracture of the pancreatic body with fluid and haemorrhage between the pancreatic fragments

Figure 2

Abdominal CT

Axial contrast-enhanced CT scan shows slight enlargement of the pancreatic tail with a fluid collection.

Figure 3

Abdominal CT

Axial contrast-enhanced CT scan shows a fluid collection at the pancreatic tail

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