Case study nhung 11.12.12


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Case study nhung 11.12.12

  1. 1. Imaging ReportLE HONG NHUNGPaediatric RadiologistNational Hospital of PeadiatricsHa Noi
  2. 2. Bui Thanh Nam, Boy 10Y , SICUDOA: December 10th, 2012Dx: Abdominal traumaClinical History: the previous 2 week, trafficaccidents:the direct impact on the upperabdomen of the wheel or the handlebars. 2-7days later feel abdominal pain, vomit => localHospital (Ninh Binh): pancrea trauma=> NHP
  3. 3. EFILM
  4. 4. Diagnosis and Classification ofPancreatic and Duodenal Injuries Introduction Mechanism Clinical Feature Laboratory Findings CT protocol Classification
  5. 5. Introduction P andD trauma is uncommon, < 2% of all abdominal injury isolated injuries (<30%). Coexisting injuries (50%–98%) Mortality for P injuries ranges from 9% to 34%; for D injuries itranges from 6% to 29% predictors of outcome: the mechanism of injury, the time todiagnosis, and duodenal perforation, Complication after 48h of survivors: pancreatitis, pseudocysts,fistulas, intraabdominal abscesses, pneumonia, development ofmultiorgan failure and septicemia When a definitive diagnosis is delayed for more than 24 hours,up to 40% of patients are at risk of death, as opposed to 11% ofthose patients operated on within 24 hours.
  6. 6. Mechanism of Injury Result from severe AP compression trauma againstthe spinal column: seat belt, wheel, handlebarcompression trauma. Blunt P trauma more common among children: lessprotection by thinner layer of peripancreatic fat. Force on R quadrant: head P, D2 and others (liver,bile duct, GB, ascending colon, R kidney) Force on L quandrant:SMA, Body P, tail, D4 andothers (spleen, stomach, L Kidney)
  7. 7. Clinical and Subclinical Feature comprise a triad of leukocytosis, raisedserum amylase activity, which can be absentin the first few days. upper abdominal pain.
  8. 8. Laboratory Findings serum amylase activity be raised, although remainsnormal for 2–48 hours after an injury. Repeated testing is recommended, for follow-upstudies and to monitor pancreatic injury Serum lipase activity is also not specific forpancreatic injury. Trypsinogen-activating peptide has not been fullyevaluated so far.
  9. 9. Imaging Protocols MD CT reduces motion artifacts and enables high-resolutionscans, thickness scanning of 2.5–5.0 mm 2 mL/kg of body weight of contrast medium injected at 3–6mL/sec with a delay of 60–70 seconds in the portal venous(60–70-second) phase. Arterial scans (25–30-second delay) in a whole-body CTprotocol or a dedicated pancreatic CT protocol (35–40-seconddelay) Delayed scanning (at 2–3 minutes) in cases of suspectedactive abdominal (including pancreatic) hemorrhage. The use of oral contrast media remains controversial, appliedto duodenum suspected to distend the duodenal wall, not likelyto used for Emergency diagnosis.
  10. 10. CT finding Duodenal Injury Duodenal perforation is suspected ifretroperitoneal collection of contrast medium,extraluminal gas, or a lack of continuity of theduodenal wall. Duodenal contusion is suspected withedema or hematoma of the duodenal wall,intramural gas accumulations, and focalduodenal wall thickening (>4 mm). Fluid or a hematoma in the retroperitoneum,
  11. 11. Duodenal Classification (AAST)
  12. 12. CT finding pancreatic injury Normal limits in the first 12 hours after the injury; The sensitivity and specificity of CT around 80%-91%(MDCT) Specific signs on CT: lacerations of the pancreas,edema or hematoma of the pancreatic parenchyma,active hemorrhage from the pancreas, and bloodcollections between the parenchyma and the splenicvein 1%
  13. 13. Pancrea injury classification (AAST)
  14. 14. ERCP and MRI ERCP can demonstrate extravasation ofcontrast medium from the pancreatic duct. If the injury of the pancreatic duct is not clear,MR imaging is used in combination withMRCP and ERCP
  15. 15. LOOK AT OUR CASE ! Edema reduce the correct imaging diagnosis:present 14 days. Active bleeding may from SMV. At admission: Grade 2-3 for DI, and Grade 2-3 for PI (not certify ductal injury).
  16. 16. MANAGEMENT- injury without ductal injury: Drainage- injury with ductal injury which can be eitherproximal or distal relative to the superior mesentericvessels:- Isolated injury :suction drainage and hence theformation of a controlled fistula,- Coexisting injury with massive destruction of P, Dmay force pancreatoduodenectomy
  17. 17. TAKE HOME POINT P and D injuries is challenging and requires closeattention to the choice of technique and the subtlesigns of injury (Normal limits in the first 12 hoursafter the injury), LAB test normal 2-48h. Repeated CT and LAB test should be consideredwhen there is a strong suspicion of pancreatic injurydespite normal findings at admission When delayed diagnosis for more than 24 hours, upto 40% of patients are at risk of death
  18. 18. Grade 1-DIFigure 1. Grade I duodenal injury. Axial CTimage shows thickening of the duodenal wall(arrow) in the descending part without evidenceof free air. There is stranding of theperipancreatic fat.
  19. 19. Grade 2- DIFigure 2a. Grade II duodenal injury. (a) Axial CT image shows an enlargedpancreatic head with mild edema (arrow) (grade I lesion). (b) CT image obtained ata lower level shows thickening of the duodenal wall in the descending part (blackarrow). Adjacent to the duodenum is a small collection of extraluminal air (whitearrow), which indicates a small grade II laceration of the wall.
  20. 20. Grade 2 - DIFigure 3. Grade II duodenal injury. Axial CT image shows agrade II injury of the horizontal part of the duodenum with smallcollections of extraluminal air (arrows). A subcapsularhematoma is present at the lower pole of the right liver lobe(arrowhead).
  21. 21. Grade 3-DIGrade III duodenal injury. AxialCT image shows thickening ofthe duodenal wall and disruptionof the wall (white arrow).
  22. 22. Grade 1- PI. Axial CT image shows aminor contusion of thepancreatic body (black arrow)Hematoma (white arrow)
  23. 23. Grade 2-PIThe pancreatic tail isslightly displaced anteriorlybecause of a peripancreatichematoma. Both adrenalglands are thickened (blackarrows), a findingsuggestive of contusion
  24. 24. Grade 3-PIAxial CT image shows diffuseedema of the pancreaticparenchyma with some definedareas of contusion (black arrow).There is a transection across thepancreatic body (white arrow).
  25. 25. Grade IV-PIAxial CT image shows a proximalpancreatic transection (blackarrow) with a large peripancreatichematoma. There is also activebleeding (white arrow)