Blunt Trauma Abdomen (BTA) – Pancreatic Injury 

 INTRODUCTION

• Pancreatic injury is rare (≈ 2–5% of blunt abdominal trauma) but high morbidity due to:
• Retroperitoneal location → delayed diagnosis
• Associated injuries (duodenum, liver, spleen)
• Most commonly due to:
• Road traffic accidents (RTA)
• Handlebar injury (children)
• Direct epigastric blow → compression against vertebral column

 ANATOMY RELEVANT TO TRAUMA

• Retroperitoneal organ (except tail tip)
• Lies anterior to vertebral column → compression injury
• Main pancreatic duct (MPD) = key determinant of prognosis
• Blood supply:
• Head → superior & inferior pancreaticoduodenal arteries
• Body/tail → splenic artery

Ductal injury = surgical disease

 MECHANISM OF INJURY

• Compression between anterior abdominal wall & spine
• Sudden deceleration → shearing at:
• Pancreatic neck (most common site)
• Crush injury → contusion → necrosis → leak

 AAST PANCREATIC INJURY SCALE 

• Grade I–II → Conservative
• Grade III+ → Usually surgery

 CLINICAL FEATURES

Early

• Epigastric pain (often mild initially)
• Vomiting
• Minimal signs (retroperitoneal organ)

Late (6–24 hrs)

• Increasing pain
• Peritonitis
• Fever
• Tachycardia
• Ileus

 Classic pitfall:
Initially normal exam → deterioration later

LABORATORY FINDINGS

• Serum amylase/lipase:
• May be normal initially
• Rising trend more important
• Leukocytosis
• CRP ↑ (inflammation)
  Normal amylase DOES NOT rule out pancreatic injury

 IMAGING 

1. CECT Abdomen (Gold Standard in stable patient)

Findings:

• Pancreatic enlargement
• Hypodense laceration
• Transection
• Peripancreatic fluid
• Fat stranding

 Important:

• CT may miss early ductal injury

2. MRCP (Best for duct)

• Non-invasive
• Detects main pancreatic duct (MPD) injury

3. ERCP (Diagnostic + Therapeutic)

• Gold standard for duct evaluation
• Allows:
• Stenting
• Leak management

4. EFAST

• Usually negative for pancreas
• May show:
• Free fluid (late)

 MANAGEMENT 

 INITIAL MANAGEMENT (ATLS PRINCIPLES)

• Airway, Breathing, Circulation
• Fluid resuscitation
• Hemodynamic stabilization
• Evaluate for associated injuries

 NON-OPERATIVE MANAGEMENT (NOM)

Indications:

• Hemodynamically stable
• Grade I–II
• No duct injury

Components:

• ICU monitoring
• NPO ??

 Start EARLY ENTERAL NUTRITION (EEN)

• Strong recommendation:
• Start within 24–48 hours
• Even in severe disease if stable
• Preferred: Post-pyloric (Nasojejunal feeding)

• IV fluids
• Analgesia
• Serial exams
• Serial amylase

 Role of:

• Somatostatin/octreotide → controversial (not routine guideline recommendation)

 ENDOSCOPIC MANAGEMENT 

• ERCP + stenting
• Indicated in:
• Partial duct injury
• Leak

 2020s trend:

• Shift toward minimally invasive duct management

 SURGICAL MANAGEMENT

Indications:

• Hemodynamic instability
• Peritonitis
• Confirmed duct injury
• Failed conservative management

 Procedure Based on Location

 Damage control approach (modern trauma care):

• Drain first → definitive surgery later

 COMPLICATIONS

Early

• Hemorrhage
• Pancreatitis
• Sepsis

Late

• Pancreatic fistula (most common)
• Pseudocyst
• Abscess
• Chronic pancreatitis
• Endocrine insufficiency (diabetes)

 PANCREATIC FISTULA 

• Defined as:
• Drain output with high amylase (>3× serum)

Management:

• Conservative (most cases)
• Drainage
• ERCP stenting if persistent

 SPECIAL SITUATIONS

 Children

• More common due to handlebar injury
• Higher NOM success

 Delayed Diagnosis

• Common (up to 24–48 hrs)
• Leads to:
• Necrosis
• Sepsis
• Worse outcome