Imaging ReportLE HONG NHUNGPaediatric RadiologistNational Hospital of PeadiatricsHa Noi
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
Diagnosis and Classification ofPancreatic and Duodenal Injuries Introduction Mechanism Clinical Feature Laboratory Findings CT protocol Classification
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.
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)
Clinical and Subclinical Feature comprise a triad of leukocytosis, raisedserum amylase activity, which can be absentin the first few days. upper abdominal pain.
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.
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.
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,
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%
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
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).
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
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
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.
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.
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).
Grade 3-DIGrade III duodenal injury. AxialCT image shows thickening ofthe duodenal wall and disruptionof the wall (white arrow).
Grade 1- PI. Axial CT image shows aminor contusion of thepancreatic body (black arrow)Hematoma (white arrow)
Grade 2-PIThe pancreatic tail isslightly displaced anteriorlybecause of a peripancreatichematoma. Both adrenalglands are thickened (blackarrows), a findingsuggestive of contusion
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).
Grade IV-PIAxial CT image shows a proximalpancreatic transection (blackarrow) with a large peripancreatichematoma. There is also activebleeding (white arrow)