Gordon by cuiliqing


									              Rob Gordon BUSM 2010
Beth Israel Deaconess Medical Center
                Dr. Gillian Lieberman
Presentation overview
  An index patient presentation
  Overview of pancreatic injury in blunt 
  abdominal trauma
  The role of multi‐row detector CT imaging
  Companion patients with imaging findings 
  suggestive of pancreatic injury
  Companion patients demonstrating imaging 
  Outcome for our index patient
  Acknowledgements and References
Our index patient:
 A 49 year old male who was an unrestrained driver in 
 a motor vehicle collision 
 He had loss of consciousness, difficulty breathing and 
 diffuse abdominal pain in the field
 Cool, pale and diaphoretic on arrival to ER. 
 BP in the field in the 90’s with HR in the 70’s
 Significant lab values: Amylase 142, Lipase 62, 
 creatinine 1.2, Hemoglobin 10 and Hematocrit 28.
CT image findings for our patient:

Axial contrast enhanced CT         Axial contrast enhanced CT
images demonstrating               images with free fluid
hypoattenuating fluid              surrounding the liver (blue star)
between the splenic vein           and peripancreatic fluid.
and posterior border of the
pancreas (blue arrow).

 All images courtesy of BMC PACS
A more concerning finding in our index 
patient is a possible pancreatic laceration
                              Axial contrast enhanced
                              CT image that shows an
                              hypoattenuating linear
                              lesion (blue arrow)
                              through the pancreas.
                              This lesion extends
                              through >50% of the

Image courtesy of BMC PACS
Some background on pancreatic 
injuries in blunt abdominal trauma:
 Pancreatic injuries caused by 
 blunt trauma is exceedingly 
 rare (incidence 0.2‐12%)
 Clinical and laboratory 
 findings are nonspecific
 Early diagnosis is critical in 
 reducing morbidity and 
 Main pancreatic duct 
 disruption is the greatest 
 predictor for complications. http://www.nativeremedies.com/images/design/ailmentPhotoPancreas.jpg
Mechanism of Pancreatic Injury 
• Blunt pancreatic injury 
  occurs with compression of 
  pancreas between the 
  vertebral column and 
  anterior abdominal wall.
     •   Adults – motor vehicle 
     •   Adolescents – bicycle 
         handlebar injuries
     •   Infants – child abuse
  Pancreatic injury is more 
  common in children and 
  young adults because of          http://www.radiologyassistant.nl/images/thmb_43ce5595362a9abdom-trauma-child-abuse.jpg

  decreased protective intra‐
  abdominal fat
Companion patient #1:
Mortality in pancreatic trauma
 Mortality rates in blunt 
 pancreatic injury range 
 from 10% to 30%

 Most deaths occur within 
 the first 48 hours due to 
 acute hemorrhage of 
 traumatized vasculature 
    splenic vein
    portal vein               Axial contrast enhanced CT image
    inferior vena cava        demonstrating transection of pancreatic
                              head and body with active extravasation of
                              contrast fluid (arrow heads).
                                      Gupta et al. Radiology 2004)
                                              Left: Companion patient 2: Axial contrast
                                              enhanced CT image with a loculated fluid
                                              collection (*) representing a pseudocyst.
                                              Gupta et al. Radiographics 2004.

    Right: Companion patient 3: Axial
    contrast enhanced CT image in a patient
    6 days after trauma showing expanding
    fluid collections within the pancreas.
    Gupta et al. Radiographics 2004.
Diagnosing Pancreatic injury:
The Role of Multi‐detector CT.
• Computed tomography is the imaging modality of choice 
  in patients with blunt abdominal trauma
• CT provides an excellent initial evaluation for the 
  detection and characterization of solid visceral organ 
• The sensitivity for pancreatic injury is between 67%‐85% 
  (mainly based on single detector CT)
• Pancreatic injuries tend to be subtle, particularly within 
  the first 12 hours after the traumatic event
• MDCT provides improved evaluation of pancreatic duct 
  integrity, which is of the utmost importance in triaging 
  patients with pancreatic injury
CT imaging findings suggestive of 
pancreatic injury: 
 Peripancreatic fluid collections
 Hyperattenuation / Active extravasation
 Contusion / Pancreatic enlargement
 Pancreatic hematoma
 Laceration / Fracture
      Companion Patient #4 and #5: Superficial 
      Lacerations without ductal involvement

                                             Below: Companion patient 5: Axial
                                             contrast enhanced CT image with
                                             superficial laceration through the tail of
                                             the pancreas. Laparotomy confirmed
                                             the pancreatic duct remained intact.
                                             Gupta et al. Radiographics 2004

Above: Companion patient 4: Axial contrast
enhanced image showing a linear
hypoattenuating line through <50% of the
pancreas. Note depth of laceration <50%
corresponds with decreased chance of main
pancreatic duct involvement.
Rekhi et al. Emergency Radiology 2009.
Companion patient 6: Axial    Companion patient 7:                             Companion patient 8:
contrast enhanced CT          Axial contrast enhanced                          Axial contrast enhanced
image showing fracture of     CT image demonstrating                           CT image with laceration
the pancreatic tail. Ductal   transection through the                          through more than 50%
involvement should be         pancreatic neck.                                 of the parenchyma.
confirmed with MRCP or                                                         Ductal disruption was
surgery.                                                                       confirmed at surgery.

                              3 images from Gupta et al. Radiographics. 2004
Companion patient # 9: 
Peripancreatic fluid Collections
 Axial contrast‐enhanced 
 CT image with significant 
 peripancreatic and intra‐
 abdominal fluid 
 collections. Peripancreatic 
 fluid is a very sensitive but 
 non‐specific imaging 
 finding in pancreatic 
 trauma. Fluid is commonly 
 found between the splenic        Image courtesy of BMC PACS

 vein and inferior border of 
 the pancrea. 
2 Axial contrast‐enhanced CT 
  images with hematoma 
  surrounding the pancreas. 
  Pancreatic hematoma present 
  as areas of heterogenous
  attenuation within or 
  surrounding the parenchyma. 
  Actively bleeding hematoma 
  will not show washout on 
  delayed phase imaging 

                                 2 images from Rekhi et al. Emergency Radiology 2009   .
                                     Below: Companion patient 12:
                                     Delayed phase image showing
                                     sustained hyperattenuation indicative
                                     of active hemorrhage.
                                     Rekhi et al. Emergency Radiology 2009.

Above: Companion patient 11: Axial
portal venous phase image showing
multiple areas of active contrast
Image courtesy of BMC PACS
Companion patient 13:                   Companion patient 14:                   Companion patient 15:
Axial contrast enhanced                 Axial contrast enhanced                 Axial contrast enhanced CT
CT image with focal                     CT image with area of                   image with area of
area of relative                        hypoattenuation within                  hypoattenuation within the
hypoattenuation within                  the body of the                         head of the pancreas.
the neck of the normally                pancreas.                               Associated with relative
enhancing parenchyma                                                            engorgement of the
indicative of pancreatic                                                        surrounding parenchyma.
Rekhi et al. Emergency Radiology 2009   Rekhi et al. Emergency Radiology 2009   Image courtesy of BMC PACS
Inherent characteristics of pancreatic 
injuries that can cause defects to be missed:

   There are a number of characteristics of pancreatic injuries that lead to 
   both false positive and false negative results on CT imaging.
   Injuries can often be subtle and require both the keen eye of the 
   radiologist and the clinical suspicion of the surgical team.
          Reasons for false negatives:
             Obscured fracture planes
             Surrounding hemorrhage
             Close apposition of pancreatic fragments
             Associated injuries – satisfaction of search
       ***many of these changes will present on follow up exams***

          Reasons for false positives: 
             Peripancreatic fluid after aggressive fluid resuscitation
             Peripancreatic fluid from an alternative source
             Atrophic or fatty pancreas
             Pancreatic clefts
Companion Patient #16: Diagnostic 
difficulties in Pancreatic trauma:
 Given the high impact 
 mechanisms, pancreatic 
 injury rarely occurs in 
 isolation. Pancreatic 
 injuries may be obscured 
 by associated injuries. 
   Associated injuries to the liver, 
   spleen, duodenum and kidneys, 
   occur in 90% of events
 Serum enzymes are neither                Axial contrast enhanced CT
 sensitive not specific                   image with splenic and right
   Initial serum amylase/lipase levels    adrenal hematoma in a patient
   normal in 40%                          with full transection of the tail of
                                          the pancreas.
                                          Rekhi et al. Emergency Radiology 2009.
Companion patient # 17:  Sources of Fluid in the 
Pararenal Space without Pancreatic injury: 

  Aggressive fluid resuscitation
  Hypovolemic shock complex 
  Blood dissecting from an 
  intraperitoneal viscus injury
  Fluid traveling via the splenorenal 
  ligament after injury to the splenic 
  Fluid traveling thorough direct 
  extension with injury to the bare area 
  of the liver
  Blood or bowel contents from duodenal 
  injury and blood
  Urine dissecting from a renal injury 
  following disruption of the posterior   Axial contrast enhanced CT image with
  renal fascia                            significant peripancreatic fluid after
                                           aggressive fluid resuscitation. The patient
                                           was treated conservatively without
                                           pancreatic complications.
                                           Rekhi et al. Emergency Radiology 2009.
Companion patient #18: Asymmetric fatty 
Atrophy of the Pancreas – Not to be confused 
with pancreatic contusion!
  Coronal (above) and axial 
   (below) contrast enhanced 
   CT images of a patient 
   with areas of 
   hypoattenuation caused by 
   separation of the 
   parenchyma by intermixed 
   fat. This normal variant 
   seen in obese and elderly 
   patients may be 
   misinterpreted as 
   pancreatic contusions or 
    2 Images courtesy of BMC PACS.
Companion patient #19: Pancreatic Clefts –
Not to be confused for pancreatic lacerations!
 Coronal (above) and axial (below) 
   contrast enhanced CT images of a 
   patient with multiple linear 
   hypoattenuating lesions with the 
   pancreas created by fat that 
   surrounds arterial and venous 
   vessels that penetrate the pancreas. 
   This is a normal variant that may be 
   misdiagnosed as fractures

     Images courtesy of BMC PACS
                                      Our patient was taken to the OR for emergent
                                      laparotomy. Findings included:

                                          •   Retroperitoneal hematoma and edema
                                          near and around the head of the pancreas.
                                          •No evidence of any active bleeding, but
                                          there was some clear fluid coming from the
                                          •Fracture through the tail of the pancreas

                                      •These findings were in agreement with our
                                      imaging findings discussed at the beginning of
                                      this presentation.

2 axial contrast enhanced images at
the level of the pancreas
2 images courtesy of BMC PACS
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 Dr. Stephan Anderson, BMC
 Dr. Gillian Lieberman, BIDMC

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