Solid organ injuries following abdominal trauma

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  • 1. SOLID ORGAN INJURIES FOLLOWING ABDOMINAL TRAUMA MODERATORS – PROF DR R.K. DEKA PROF DR H.K. BHATTACHARYYA PROF DR A. AHMED PRESENTED BY- DR AYMEN AHMAD KHAN PGT SURGERY
  • 2. INTRODUCTION Motor vehicle accidents are responsible for 75% of all blunt trauma abdominal injuries More common in elderly due to less resilience. Blunt injuries causes solid organ trauma (spleen, liver and kidneys) more often than hollow viscera. Multi organ injury and multiple system injury are also more common in blunt injury than in other types. Spleen is most common intra abdominal organ to be injured followed by liver.
  • 3. ORGAN INJURIES SOLID ORGANS- • Solid organs most commonly injured in blunt traumas • In decreasing incidence of injury • Spleen, liver, kidneys, intraperitoneal small bowel, bladder, colon, diaphragm, pancreas and duodenum HOLLOWVISCERA: - duodenum commonly injured - Small bowel injured at relatively fixed areas (duodenojejunal flexure and ileocaecal junction) by shearing force - Colon relatively protected. - Gaseous distension of caecum – most vulnerable part as fixed. - Stomach rarely injured – compression cause esophagogastric junction bursting
  • 4. RETROPERITONEUM AND UROGENITALTRACT • Kidney injury - common next to spleen and liver • Pancreatic injury - 4% cases of trauma • Bladder - most commonly injured extra peritoneally by shearing at the vesico urethral junction. - intraperitoneally by blunt force on distended bladder • Rupture of prostatic urethra by shear forces is commonly seen with haemorrhage CHILDHOODTRAUMA • Blunt trauma secondary to MVAs, falls or child abuse is primarily responsible for 90% of childhood injuries. • Predominance - Solid organ abdominal injuries. • Non-op. management – 90% success rate (standard of care in solid organ injuries) • Overall mortality – approx 15% or < (if major vascular injuries excluded) • Mortality from severe blunt trauma abdomen is higher than penetrating injuries
  • 5. MECHANISM OF INJURY • Direct application of a blunt force to the abdomenCRUSHING • Sudden decelerations apply a shearing force across organs with fixed attachments SHEARING • Raised intraluminal pressure by abdominal compression accurately in hollow organs can lead to rupture BURSTING • Disruption of bony areas by blunt trauma may generate bony spicules that can cause secondary penetrating injury PENETRATION
  • 6. BLUNT ABDOMINALTRAUMA • Direct impact or movement of organs • Compressive, stretching or shearing forces • Solid Organs > Blood Loss • Hollow Organs > Blood Loss and Peritoneal Contamination • Retroperitoneal > Often asymptomatic initially
  • 7. PRESENTATION • Varies widely from haemodynamic stability with minimal abdominal signs to complete cardiovascular collapse and may change from one to the other with alarming rapidity
  • 8. INITIAL ASSESSMENT Whether the patient is haemodynamically -stable -unstable FIRST PRIORITIES PROTOCOL : • Brief clinical examination to evaluate ABC along with cardiovascular status with blood pressure and pulse measurement Accordingly, resuscitation and management of shock by • maintenance of ABC • IV fluids • nasogastric tube insertion • Catheterization
  • 9. SECOND PRIORITIES PROTOCOL Physical examination Base line investigations Four quadrant tap Diagnostic peritoneal lavage (DPL) Ultrasound – FAST (focus assessment with sonography for trauma) Abdominal CT scan Diagnostic laparoscopy Laparotomy
  • 10. PHYSICAL EXAMINATION General Examination : relating to hemodynamic stability Abdominal findings: Inspection : • for abdominal distension • for contusions or abrasions • lap belt ecchymosis – mesenteric, bowel, and lumbar spine injuries • periumblical (Cullen sign) and flank (GreyTurner Sign) ecchymosis – retroperitoneal haematoma
  • 11. Palpation : • for tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum Percussion : • Dullness/ shifting dullness – intrabdominal collection Auscultation : • bowel sounds present/absent. Rectal findings Check for gross blood - pelvic fracture Determine prostate position – high riding prostate – urethral injury Assess sphincter tone – neurologic status
  • 12. DIAGNOSTIC STRATEGY to identify those with injuries to decide which ones need laparotomy how quickly this must be undertaken
  • 13. BASIC INVESTIGATIONS • Complete haemogram with hematocrit, ABG, Electrocardiogram • Renal function tests • Urine analysis – • +nce of hematuria – genito urinary injury • -nce of hematuria – does not rule out it • Serum amylase / lipase or liver enzymes - se -suspicion of intraabdominal injuries
  • 14. • Chest radiograph – • Pneumothorax/hemothorax • Raised left/right hemidiaphragm – perisplenic/hepatic hematoma. • Lower ribs fracture – liver/spleen injury. • Abdominal contents in the chest – • ruptured hemidiaphragm • Abdominal radiographs – - Pneumoperitoneum –perforation of hollow viscus - Ground glass appearance –massive hemoperitoneum
  • 15. - Dilated gut loops- retroperitoneal hematoma or injury - Retroperitoneal air outlining the right kidney – duodenal injury - Double wall sign – air inside and outside the bowel - Distortion or enlargement of outlines of viscera – hematoma in relation to respective organs - Medial displacement of stomach – splenic hematoma - Obliteration of Psoas shadow – retroperitoneal bleeding - Pelvic bone fracture – bladder/urethral/rectal injury - Fracture vertebra – ureter injury / retroperitoneal hematoma
  • 16. INDICATIONS FOR FURTHERTESTING Unexplained haemorrhagic shock Major chest or pelvic injuries Abdominal tenderness Diminished pain response due to - • Intoxication • Depressed level of consciousness • Distracting pain • Paralysis Inability to perform serial examination
  • 17. FOUR QUADRANT TAP: Overall accuracy – about 90% Positive tap – obtaining 0.1 ml or more of non clotting blood Negative tap does not rule out haemorrhage DIAGNOSTIC PERITONEAL LAVAGE Criteria for positive tap – Gross bloody tap >1,00,000 RBCs per mm > 500 white blood cells per mm Elevated amylase level Presence of bile or bacteria or faeces
  • 18. ULTRASOUND FAST EXAMINATIONS (focused assessment with sonography for trauma). ADVANTAGES Inexpensive, noninvasive and portable Performed by emergency physicians and surgeons trained in performing FAST examinations. Avoids risks associated with contrast media Confirms presence of hemoperitoneum in minutes •Deceases time to laparotomy •Great adjunct during multiple casualty disasters Serial examination can detect ongoing hemorrhage Differentiates pulseless electrical activity from extreme hypotension
  • 19. DISADVANTAGES A minimum of 70 ml of intraperitoneal fluid for positive study. Accuracy is dependent on operator / interpreter skill and is decreased with prior abdominal surgery. Technically difficult with – obese, ileus or subcutaenous emphysema is present Does not define exact cause of hemoperitoneum Sensitivity is low for small-bowel and pancreatic injury Sensitivity – 69%- 99%
  • 20. Technique - Four basic transducer positions used to find abdominal fluid.
  • 21. ABDOMINAL CT SCAN -Latest generation of helical and multislice scanners provides rapid and accurate diagnostic information. -Criterion standard for solid organ injuries. -Help quantitate the amount of blood in the abdomen and can reveal individual organs with precision
  • 22. Diagnostic Modalities in AbdominalTrauma
  • 23. * Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in blunt abdominal trauma. JTrauma 29:242, 1999. ** Meyer D M,Thal E R,Weigelt J A, et al:The role of abdominal CT in the evaluation of stab wounds to the back. JTrauma 29:1226, 1999.
  • 24. LAPAROSCOPY ADVANTAGES extent of organ injuries and determines the need for laparotomy Defines which intraabdominal injuries may be safely managed nonsurgically More sensitive than DPL or CT in uncovering - • Diaphragmatic injuries • Hollow viscus injuries Surgery can be done in same sitting • With laparoscope with minimal trauma • Open surgery DISADVANTAGES: pneumoperitoneum may elevate ICP General anesthesia usually necessary Patient must be hemodynamically stable
  • 25. LAPAROTOMY Peritonitis (gross blood, bile or faeces) Pneumoperitoneum or pneumoretroperitoneum Evidence of diaphragmatic defect Gross blood from stomach or rectum Abdominal distension with hypotension Positive diagnostic test for an injury requiring operative repair INDICATIONS
  • 26. SPLENIC INJURY The spleen is the intra-abdominal organ most frequently injured in blunt trauma Spleen lies in posterior portion of lt upper quadrant, deep to ninth ,tenth and eleven ribs Convex surface lies under lt hemidiaphargm Concavities on medial side due to impression by neighbouring structures Average length 7-11cm Weight 150 grams (70-250) Tail of pancreas lies incontact with spleen in 30% and within 1cm in 70%
  • 27. Arterial Supply andVenous drainage Splenic artery provides major blood supply Arises from coeliac artery (ocassionaly aorta or SMA) Tortrous course (average 13 cm) Small blood supply from short gastric vessels. Venous drainage is through splenic vein Joins superior mesenteric vein to form portal vein
  • 28. SUSPENSORY LIGAMENTS Provide attachment of spleen with adjacent structures These ligaments are avascular except gastrosplenic ligament (containing short gastric and gastroepiploic artery) GASTROSPLENIC SPLENORENAL SPLENOPHRENIC SPLENORENAL
  • 29. PRESENTATION Patient may present with the upper abdominal or flank pain Referred pain to the shoulder (kehr sign) Some may be asymptomatic Physical examination is insensitive and non specific. Pt may have signs of lt upper quadrant tenderness or signs of generalized peritoneal irritation. May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)
  • 30. Organ Injury Scaling-American Association of the Surgery ofTrauma (OIS-AAST)
  • 31. MANAGEMENT Nonoperative management of splenic injury is successful in >90% of children, irrespective of the grade of splenic injury. Non operative management successful in adults 65% unstable patients suspected of splenic injury and intra-abdominal hemorrhage should undergo exploratory laparotomy and splenic repair or removal. blunt trauma patient with evidence of hemodynamic instability unresponsive to fluid challenge with no other signs of external hemorrhage should be considered to have a life-threatening solid organ (splenic) injury until proven otherwise.
  • 32. FLOWCHART FOR MANAGEMENT
  • 33. Criteria for non operative management Haemodynamic stability Negative abdominal scan Absence of contrast extravasation on CT Absence of other clear indications for exploratory laprotomy Absence of conditions associated with increased risk of bleeding (Coagulopathy, use of anticoagulants, cardiac failure, ) Failure rate for non operative(Adults) GRADE 1 - 5% GRADE 2 - 10% GRADE 3 - 20% GRADE 4 - 33% GRADE 5 - 75%
  • 34. SURGERY • operative therapy of choice is splenic conservation where possible to avoid the risk of death from opportunistic postsplenectomy sepsis that can occur after splenectomy for trauma. However, in the presence of multiple injuries or critical instability, splenectomy is more rapid and judicious. SPLENECTOMY • Exploration is through a long midline incision.The abdomen is packed and explored. Exsanguinating hemorrhage and gastrointestinal soilage are controlled first • splenic ligamentous attachments are taken down sharply or bluntly to allow for rotation of the spleen and the vasculature to the center of the abdominal wound and to identify the splenic artery and vein for ligation.
  • 35. • Once the splenic artery and vein are identified and controlled by ligation, • The gastrosplenic ligament with the short gastric vessels is divided and ligated near the spleen to avoid injury or late necrosis of the gastric wall. • Drains are typically unnecessary unless concern exists over injury to the tail of the pancreas during operation.
  • 36. SPLENORRAHPHY • Parenchyma saving operation of spleen • The technique is dictated by the magnitude of the splenic injury • Nonbleeding grade I splenic injury may require no further treatment.Topical hemostatic agents, an argon beam coagulator, or electrocautery • In grade 2 and 3 suture repair (horizontal mattress) , or mesh wrap of capsular defects. Suture repair in adults often requiresTeflon pledgets to avoid tearing of the splenic capsule
  • 37. PARTIAL SPLENECTOMY • Grade IV toV splenic injury may require anatomic resection, including ligation of the lobar artery. AUTOTRANSPLANTATION • implanting multiple 1-mm slices of the spleen in the omentum after splenectomy. • This technique remains experimental ,role controversial
  • 38. POST OPERATIVE CARE • Recurrent bleeding in the case of splenorrhaphy or new bleeding from missed or inadequately ligated vascular structures should be considered in the first 24-48 hours. • Immunizations against Pneumococcus species as a routine of postoperative management.(24 hours - 2 weeks) • Some centers also routinely vaccinate for Haemophilus and Meningococcus species
  • 39. COMPLICATIONS Early: • Bleeding • Acute gastric distension • Gastric necrosis • Rebleeding from splenic bed • Pancreatitis • Subphrenic abscess Late : • OPSI (1-6WEEKS) • DVT
  • 40. DVT FOLLOWING SPLENECTOMY • Splenectomy  thrombocytosis ( platelets)  increases risk of DVT • Portal vein thrombosis • Abd pain, anorexia, thrombocytosis • CT with IV contrast • Prevention of DVT • Sequential compression devises on legs • Subcutaneous heparin
  • 41. Opportunistic Post Splenectomy Infection (OPSI) • 3% of splenectomy patients • Higher mortality in children (especially thalassemia and SS) • Decreased since use of pneumococcal vaccine • Pneumonia or meningitis in half the cases • Very rapid onset of symptoms and signs • More than half die within 2 days of admission • Within 2 years of splenectomy, especially children Single daily dose of penicllin or amoxicillin for 2 yrs
  • 42. FOLLOW UP OF POST SPLENECTOMY PATIENTS • revaccination with pneumococcal vaccine after 4-5 years one time only. • Patients should be warned about the increased risk of postsplenectomy sepsis and should consider lifelong antibiotic prophylaxis for invasive medical procedures and dental work. • Notify their doctor immediately of any acute febrile illness • Seek prompt treatment even after minor dog bite or other animal bite.
  • 43. LIVER INJURY • The liver is the largest solid abdominal organ and is commonly injured with abdominal trauma. • It has a thin capsule with friable parenchyma and is found in a fixed position between bony structures, which renders it susceptible to crushing injuries. • Its dual blood supply implies that injuries can result in significant blood loss. • The right lobe is larger than the left and is more frequently injured. • Segments 6, 7 and 8 are involved in 85% of injuries, commonly due to compression against the fixed ribs, spine and posterior abdominal wall. • Given their pliable ribs and a weaker parenchymal connective tissue network, children are more susceptible to blunt liver injury.
  • 44. DIAGNOSIS OF LIVER INJURY • Focused assessment sonography in trauma (FAST) performed in the emergency room by an experienced operator can reliably diagnose free intraperitoneal fluid. • Patients with free intraperitoneal fluid on FAST and haemodynamic instability, and • patients with a penetrating wound will require a laparotomy and/or thoracotomy once active resuscitation is under way.
  • 45. CT Grading of liver trauma is based on the American Association for the Surgery of Trauma (AAST) injury scale
  • 46. Management according to the Grade Grade I,II ---minor injuries, represent 80-90% of all injuries, require minimal or no operative treatment Grade III-V -- severe,require surgical intervention GradeVI --incompatible with survival
  • 47. Non-Operative Management of Liver Injury • An absolute increase in the incidence of non operatively managed liver injuries (NOMLI) is unequivocal. • Multiple studies have shown that NOMLI is effective Criteria for NOMLI • No indications for laparotomy (physical examination signs/symptoms or other injuries) • Hemodynamically normal after resuscitation with crystalloid • No injuries that preclude physical examination of the abdomen (e.g., CHI, spinal cord injury) • No transfusion requirements (PRBC) • Constant availability of surgical and critical care resources
  • 48. COMPLICATIONS OF NOMLI • Biliary (bile peritonitis, bile leak, biloma, hemobelia..) • Infection (liver abscess, necrosis, abdominal sepsis, SIRs) • Abdominal compartment syndrome • Hemorrhage • Hepatic necrosis &/or Acalculous Cholecystitis FAILURE OF NOMLI • Usually attributed to reasons unrelated to liver injury • Other injuries can be missed in a blunt trauma victims, such as: • Bowel • Pancreas • Diaphragm • Bladder Which can lead to failure of NOMLI
  • 49. OPERATIVE MANAGEMENT INDICATIONS BLUNTTRAUMA • Hemodynamic instability • Transfusion> 2 blood volume or > 40 ml/kg • Devitalized parenchyma • Sepsis / biloma PENETRATINGTRAUMA • Exploratory lapratomy is indicated in any penetrating trauma in with peritoneal penetration
  • 50. OPERATIVE INTERVENTIONS • Initial control of bleeding achieved with temporary tamponade using packs, portal triad occlusion(Pringle manoeuvre), bimanual compression of the liver or even manual compression abdominal aorta above celiac trunk • If hemorrhage is unaffected by portal triad occlusion(Pringle manoeuvre) by digital compression or vascular clamp, major vena cava injury or atypical vascular anatomy should be expected Perihepatic packing --Indication: coagulopathy, irreversible shock from blood loss (10u), hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries
  • 51. HEPATOTOMY WITH DIRECT SUTURE LIGATION • using the finger fracture technique, electrocautery or an ultrasonic dissector to expose damaged vessels and hepatic duct which ligated , clipped or repaired • low incidence of rebleeding, necrosis and sepsis • effectives following blunt liver trauma requires further evaluation RESECTION DEBRIDEMENT • removal devitalized tissue • rapid compared with standard anatomical resection, which are more time consuming and remove more normal liver parenchyma • reduced risk of post-op sepsis secondary hemorrhage and bile leakage
  • 52. MESH WRAPPING • --new technique for grade III,IV laceration, tamponading large intrahepatic hematomas • --not indicated where juxtacaval or hepatic vein injury is suspected • Anatomical resection • --reserved for deep laceration involving major vessels or bile ducts, extensive devascularization and major hepatic venous bleeding OTHER OPERATIVE INTERVENTIONS • Omental packing • Intrahepatic tamponade with penrose drains • Fibrin glue • Retrohepatic venous injuries --CompleteVascular isolation of the liver --venovenous bypass --Atriocaval shunting • Liver transplantation
  • 53. COMPLICATIONS --Hemorrhage,sepsis --Biliary fistula --Respiratory problems --Liver failure --Hyperpyrexia --Acalculous cholecystitis --Pancreatic, duodenal or small bowel fistula
  • 54. RENALTRAUMA The kidney is injured in approximately 10% of all significant blunt abdominal trauma. Of those, 13% are sports-related when the kidney, followed by testicle, is most frequently involved. However, the most frequent cause by far is motor vehicle accident followed by falls Renal lacerations and renal vascular injuries make up only 10-15% of all blunt renal injuries. Isolated renal artery injury following blunt abdominal trauma is extremely rare, and accounts for less than 0.1% of all trauma patients
  • 55. DIAGNOSIS AND INITIAL EMERGENCY ASSESSMENT • Initial assessment of the trauma patient should include securing the airway, controlling external bleeding, and resuscitation of shock. • In many cases, physical examination is carried out during the stabilisation of the patient. • Pre-existing renal abnormality makes renal injury more likely following trauma.
  • 56. The following findings on physical examination could indicate possible renal involvement: • haematuria; • flank pain; • flank ecchymoses; • flank abrasions; • fractured ribs; • abdominal distension; • abdominal mass; • abdominal tenderness.
  • 57. INDICATION FOR FURTHER IMAGING Gross haematuria Microscopic haematuria with haemodynamic instability Persistant microscopic haematuria
  • 58. CT WITH INTRAVENOUS CONTRAST Gold standard Immediate and delayed post contrast images to view collecting system Allows diagnosis and staging Images abdomen and retroperitoneum Not for haemodynamic unstable patients
  • 59. INTRAVENOUS PYELOGRAPHY Unable to evaluate abdomen and retroperitoneum Inadequate for grading renal injury Used in unstable pat prior to surgery to identify functioning contralateral kidney
  • 60. RENAL ANGIOGRAPHY Delineates vascular injury (intimal tears, pseudoaneurysm, AV fistulas) Use when CT equivocal and continued haemorrhage Use for endo vascular repair (embolization, stenting)
  • 61. RENAL ULTRASOUND Evaluation of abd/pelvic injury/fluid acclumation High false neg rate for renal injury Used in areas without CT or for follow up
  • 62. AAST renal injury grading scale
  • 63. NON-OPERATIVE MANAGEMENT OF RENAL INJURIES All grade 1 and 2 renal injuries can be managed non-operatively, whether due to blunt or penetrating trauma. Therapy of grade 3 injuries has been controversial, but recent studies support expectant treatment Patients diagnosed with urinary extravasation in solitary injuries can be managed without major intervention and a resolution rate of > 90%. In stable patients, supportive care with bed-rest, hydration,antibiotics & continuous monitoring of vital signs until haematuria resolves is the preferred initial approach. The failure of conservative therapy is low (1.1%)
  • 64. SURGICAL MANAGEMENT - haemodynamic instability; - exploration for associated injuries; - expanding or pulsatile peri-renal haematoma identified during laparotomy; - grade 5 injury. -pre-existing renal pathology requiring surgical therapy
  • 65. OPERATIVE FINDINGS AND RECONSTRUCTION The goal of renal exploration is control of haemorrhage and renal salvage. the transperitoneal approach for surgery as access to the renal vascular pedicle is then obtained through the posterior parietal peritoneum, which is incised over the aorta, just medial to the inferior mesenteric vein. Temporary vascular occlusion before opening Gerota’s fascia is a safe and effective method during exploration and renal reconstruction as it tends to lower blood loss and the nephrectomy rate. The overall rate of patients who have a nephrectomy during exploration is around 13%. Generally in penetrating and gun shot injuries where renal reconstruction is difficult
  • 66. Renal reconstruction should be attempted in cases where the primary goal of controlling haemorrhage is achieved and a sufficient amount of renal parenchyma is viable. Renorrhaphy is the most common reconstructive technique. Partial nephrectomy is required when non-viable tissue is detected. Watertight closure of the collecting system, if open, might be desirable, although some experts merely close the parenchyma over the injured collecting system with good results. If the renal capsule is not preserved, an omental pedicle flap or peri-renal fat bolster may be used for coverage . In all cases, drainage of the ipsilateral retroperitoneum is recommended to provide an outlet for any temporary leakage of urine.
  • 67. Renovascular injuries are uncommon. Non-operative management for segmental renal artery injury results in excellent outcomes Following blunt trauma, repair of grade 5 vascular injury is seldom if ever effective. Repair could be attempted in which there is a solitary kidney or the patient has sustained bilateral injuries. In all other cases, nephrectomy appears to be the treatment of choice. Angiography with selective renal embolisation for haemorrhage control is a reasonable alternative to laparotomy provided that no other indication for immediate surgery exists The complication rate is minimal. Effective for grade 4 injuries where conservative therapy failed.
  • 68. FOLLOW UP Repeat imaging within 2-4 days of significant renal. Within 3 months of major renal injury, patients’ follow- up should involve: 1. physical examination; 2. urinalysis; 3. individualised radiological investigation; 4. serial blood pressure measurement; 5. serum determination of renal function
  • 69. COMPLICATIONS EARLY ( < 1 MONTH) BLEEDING. INFECTION PERI-NEPHRIC ABSCESS SEPSIS URINARY FISTULA HYPERTENSION URINARY EXTRAVASATION URINOMA DELAYED BLEEDING HYDRONEPHROSIS CALCULUS FORMATION CHRONIC PYELONEPHRITIS HYPERTENSION ARTERIOVENOUS FISTULA HYDRONEPHROSIS PSEUDOANEURYSMS.
  • 70. PANCREATIC INJURY • Pancreatic injuries caused by blunt trauma is exceedingly rare (incidence 0.2‐12%) • Clinical and laboratory findings are nonspecific • Early diagnosis is critical in reducing morbidity and mortality • Main pancreatic duct disruption is the greatest predictor for complications. • Mortality rates in blunt pancreatic injury range from 10% to 30%. • Most deaths occur within the first 48 hours due to acute haemorrhage of traumatized vasculature including: - splenic vein - portal vein - inferior vena cava
  • 71. MECHANISM OF INJURY • Blunt pancreatic injury occurs with compression of pancreas between the vertebral column and anterior abdominal wall. Adults – motor vehicle accidents Adolescents –bicycle handlebar injuries Infants –child abuse • Pancreatic injury is more common in children and young adults because of decreased protective intra‐abdominal fat
  • 72. DIAGNOSIS SERUM AMYLASE LEVEL Suggest only pancreatic injury Cannot predict or correlate with the degree of injury SERUM LIPASE LEVEL nonspecific and a poor indication of injury elevated levels may provide a clue to a severe injury requiring further investigation
  • 73. ULTRASOUND diagnosis of free abdominal fluid or gross damage to the liver or spleen can be done The pancreas is not easily identified pancreatic injuries, parenchymal or ductal, are frequently missed. diagnosis of an other intra- abdominal injury and need for an urgent explorative laparotomy can be done
  • 74. MULTI‐DETECTOR CT imaging modality of choice in patients with blunt abdominal trauma excellent initial evaluation for the detection and characterization of solid visceral organ injury The sensitivity for pancreatic injury is between 67%‐85% Pancreatic injuries tend to be subtle, particularly within the first 12 hours after the traumatic event MDCT provides improved evaluation of pancreatic duct integrity, which is of the utmost importance in triaging patients with pancreatic injury
  • 75. MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY high sensitivity and specificity Non invasive detection or exclusion of pancreatic duct trauma and pancreatic specific complications Unable to provide real-time visualization of ductal findings and extravasation
  • 76. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY sensitivity and specificity of 100% demonstrate clearly the site of duct disruption and the grade of duct injury effective and safe non- operative treatment tool leakages of the pancreatic duct, trans papillary stent insertion might seal the injury and stabilize it
  • 77. TREATMENT ALGORITHM
  • 78. NONOPER ATIVE MANAGE MENT absence of a ductal injury (grade I and II) consists of bowel arrest, total parental nutrition serial imaging with either CT scans or ultrasound to follow injury resolution
  • 79. PROXIMAL DUCT INJURY Incomplete / complete disruption of the MPD without duct obstruction is the best candidate for the pancreatic duct stent therapy Transductal pancreatic stent allows internal drainage of the pancreatic secretion and re- establishment of duct continuity GRADE IV INJURIESWITH PDI In stable patients, pancreaticoduodenectomy is the best definite treatment In unstable patients, exploration and placing of external drainage may be the best choice for damage control
  • 80. DISTAL PANCREATIC INJURY WITH DUCT INVOLVEMENT wounds in the body or tail of the pancreas with an obvious duct injury or transection of more than half the width of the pancreas these grade III injuries are best treated by distal pancreatectomy complete transection of the pancreatic body from the head, a distal Pancreaticojejunostomy and closure of the proximal end of the pancreas rupture
  • 81. COMPLICATIO NS fistula pancrea tic abscess pseudocyst formation sepsis