Introduction
Unlike the liver, kidney, or spleen, conventional imaging methods does not pick up on minute indications connected to pancreatic injury. After the first event, post-traumatic pancreatitis may take several hours to change the blood or induce edema. Magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) may be necessary for diagnostic testing.
Complications such as infection, pseudocysts, abscesses, duct strictures, peritonitis, and endocrine/exocrine insufficiency that are linked to significant morbidity and mortality, resulting in a delay in diagnosis. An incorrect classification prevents effective management and intervention. To properly recognize, categorize, and treat traumatic pancreatitis, a high level of suspicion and thorough understanding are needed.
What Is the Etiology of Pancreatic Trauma?
A common aftereffect of penetrating trauma is traumatic pancreatic damage. Blunt trauma, such as child bicycle handlebar injuries, adult car accident steering wheel injuries, or a direct kick during an assault, results in a quick localized impact to the abdomen, compressing the intraabdominal organs against the spinal column and possibly injuring the pancreas. Identification of the main pancreatic duct disruption is essential because it is the main factor in delayed consequences. 90 % of instances involving pancreatic injuries also involve damage to another abdominal organ; the most frequent of these is a duodenal-pancreatic injury.
What Is the Epidemiology of Pancreatic Trauma?
Pancreatic injury is uncommon, occurring in only 0.2 % to 1.1 % of all trauma cases, according to reports. The remaining 37 % are the result of blunt abdominal trauma, with 63 % coming from penetrating gunshot and stab wounds. According to some sources, the prevalence of pancreatic injury in abdominal trauma ranges from about 3 % to 12 % and from 0.2 % to 2 % overall. Pancreatic injury mortality has ranged from 9 % to 34 %. According to a level 1 trauma center, morbidity might reach 64 %. About 30 % of patients with traumatic pancreatic damage exhibit isolated pancreatic injuries, and only 5 % of these cases result in fatalities. Because there is less fat for insulation, blunt pancreatic trauma occurs more frequently in children.
What Is the Pathophysiology of Pancreatic Trauma?
The pancreas is a retroperitoneal organ that is located close to the level of L1-L2 in the epigastric region and is oriented transversely. Given that it is situated on the dorsal side of the belly, the pancreas has certain built-in defenses. It is separated histologically into two halves and is long, J-shaped, lobulated, and divided.
Alpha, beta, and gamma cells in the endocrine pancreas, which produce the hormones glucagon, insulin, and somatostatin, respectively, are the first. The second is the acinar or exocrine part, which secretes bile at the ampulla of Vater through the sphincter of Oddi, along with lipase, amylase, and proteolytic enzymes, into the duodenum. When disturbed, the primary pancreatic duct of Wirsung, which runs transversely through the entire pancreas, causes delayed problems.
Blood enters the head, body, and tail through pancreatic vessels that branch off the spleen while leaving the body through the superior mesenteric and portal veins. Nearness to important blood vessels necessitates a challenging surgical technique at the risk of severe hemorrhagic exsanguination.
Primary mortality in pancreatic trauma is caused by hemorrhage. Little and large intestine wounds are more likely to develop infectious consequences because they expose patients to bacterial flora, which can result in gram-negative sepsis. Ductal disruption causes proteolytic enzymes to flow into other organs, where they cause abscesses and fistulas to form at rates of 50 % and 25 %, respectively.
A pancreatic pseudocyst, a confined accumulation of enzymes, blood, and necrotic tissue, is another consequence. Peritonitis, intestinal blockage, and gastrointestinal bleeding are less common consequences. Patients' endocrine functions can be affected by pancreatic damage as well. As a result, patients who experience acute pancreatic injury are more susceptible to both the immediate and long-term effects of this disease process.
What Is the History of Pancreatic Trauma?
Traumatic pancreatitis can be challenging to diagnose and calls for thorough research. The pancreas rarely sustains a single injury and is rarely damaged frequently. In addition to its natural retroperitoneal position, pancreatic damage is concealed by concurrent intraabdominal injuries. Symptoms of radiating epigastric pain to the back, nausea, and vomiting are also reported with the more usually injured neighboring viscera. An initial evaluation of an abdominal exam is said to have a 34 % false negative rate. A strong index of suspicion is required due to the nonspecific nature of the symptoms and indications in order to avoid a delayed diagnosis.
How to Evaluate Pancreatic Trauma?
The majority of cases of pancreatic damage are not diagnosed until serious complications arise since it is so difficult to make a diagnosis. Testing in laboratories is rarely beneficial. Amylase levels are normal in 30 % to 35 % of individuals with total pancreatic transection or fracture, despite the fact that serum lipase and amylase are neither specific nor sensitive to pancreatic injury. Although amylase levels can be raised in the head, neck, salivary gland, liver, and duodenal injuries, as well as intoxication from alcohol, there is a poor connection between amylase levels in deep peritoneal lavage and traumatic pancreatitis.
Modern trauma evaluation includes radiography and ultrasonography as essential components. When there has been penetrating trauma, a plain X-ray can help identify a foreign body. Although quick and convenient, ultrasound (US) has limited sensitivity for the detection of acute traumatic pancreatitis.
The pancreas may expand, swell, and secrete secretions. Pseudocysts and other duct damage consequences can be reliably detected with ultrasound. The preferred test for hemodynamically stable trauma patients with blunt abdominal injuries is computerized tomography (CT). However, it can be challenging to detect pancreatic injury, especially in the early stages after injury, when 20 % to 40 % of CTs initially appear normal within 12 hours of trauma.
Laceration, transaction, focal enlargement, and augmentation are direct indicators of injury. Other symptoms include damage to nearby tissues, peripancreatic fat stranding, peripancreatic fluid, bleeding, and hematoma. A fracture or a distinct separation of fragments are two telltale markers of pancreatic injury that a CT scan might detect. Moreover, it can detect intrapancreatic hematoma, a particular form of traumatic pancreatitis.
What Is the Treatment of Pancreatic Trauma?
Polytrauma and numerous organ impairments frequently accompany pancreatic injuries. Resuscitation and hemodynamic stabilization are the first lines of treatment, focusing on reducing stomach contents leakage and controlling hemorrhage. Damage to the main pancreatic duct, the amount of parenchyma involved, the site of the injury, the patient's stability, and other injuries will determine the course of treatment.
The placement of a nasogastric tube with suction, bowel rest, and nutritional supplementation are all components of conservative treatment. Currently, there is no clear purpose for using octreotide, a synthetic somatostatin analog, to treat severe pancreatic damage. Octreotide use was associated with a lower complication rate, according to a short trial involving 28 patients. A somewhat bigger study, however, found no variation in the complication rate.
A major pancreatic duct injury is treated with ERCP-guided stent insertion or drainage. Exploratory laparotomy is typically required for penetrating injuries. When a substantial pancreatic injury results from acute abdominal trauma within 24 hours, morbidity and mortality significantly rise without surgical intervention. Simple drainage, pyloric exclusion, duodenal diversion, or, in extreme situations, a Whipple procedure are among the surgical interventions that can be used. The Whipple surgery is divided into two independent surgeries, damage control, and anastomoses if the patient is hemodynamically unstable.
Conclusion
A rip, cut, or bruise to the pancreas is an example of blunt trauma to the organ. Internal bleeding could result from these wounds if an organ ruptures or if there are issues with the blood vessels. The pancreas may eventually heal with care and treatment, and significant issues may be avoided.
