Management of Pancreatic Injuries

Annotation for Point A

Pancreatic injuries are generally recognized either by computed tomographic (CT) scan or at exploratory laparotomy (LAP). Patients who have abdominal pain or tenderness or who have sustained a high-risk injury mechanism should undergo abdominal CT scan at the time of presentation. Patients who later develop abdominal pain or tenderness need further evaluation. Leukocytosis, unexplained metabolic acidosis, or fever may also herald an occult injury. The utility of serum amylase and lipase assays has been debated, and enzyme levels should not be relied upon to either diagnose or exclude pancreatic injury. The noninvasive diagnosis of pancreatic injuries can be challenging. The primary nonoperative diagnostic modality for pancreatic injury is CT scanning. Findings may be subtle, particularly when the imaging is performed within 12 hours of injury.2 Specific signs of injury include fractures or lacerations of the pancreas, active hemorrhage from the gland, or contusion, edema or hematoma of the parenchyma. Nonspecific findings include peripancreatic blood or fat stranding.2 The reported sensitivity and specificity of earlier-generation helical CT scan for pancreatic injuries was in the range between 70% and 80%.2,3 Subsequent data suggested that multidetector row CT (MDCT), with imaging timed during the portal venous phase, could achieve 100% accuracy of not only pancreatic injuries but also pancreatic ductal injuries.4 However, a recent American Association for the Surgery of Trauma (AAST)multicenter study questions the accuracy of 16- and 64-MDCT for detecting pancreatic injury in general and pancreatic ductal injury specifically. Although specificity was better than 90%, the sensitivity of MDCT for either injury was only 47%to 60%.5 Ultimately, the accuracy of CT is dependent on not just the technology but also the technique, the timing after injury, and the skills of the interpreting clinician. In the face of a normal initial CT scan, if a pancreatic injury is clinically suspected, CT should be repeated.