Trauma/Emergency RadiologyFree Access

Pancreatic Trauma: Imaging Review and Management Update

Published Online:https://doi.org/10.1148/rg.2021200077

Abstract

Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury–related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage.

©RSNA, 2020

See discussion on this article by Patlas.

SA-CME LEARNING OBJECTIVES

After completing this journal-based SA-CME activity, participants will be able to:

  • ■ Discuss the mechanism of injury, clinical features, imaging findings, and potential complications of pancreatic trauma.

  • ■ Assign the appropriate AAST-OIS grade for traumatic pancreatic injuries on the basis of imaging findings.

  • ■ Explain the management options for pancreatic trauma in relation to imaging findings, AAST-OIS grade, and patient factors.

Introduction

Teaching Point Pancreatic injuries can be difficult to diagnose, given the low frequency of these injuries and the associated nonspecific clinical features, subtle imaging findings, and multiorgan trauma.
Owing to their shielded retroperitoneal location, pancreatic injuries occur in only about 2% of all patients with trauma injuries and in 10% of those with other intra-abdominal injuries (13). Although most cases of pancreatic injury are secondary to blunt trauma, those from penetrating trauma occur more frequently on a per-case basis, and penetrating trauma may more frequently involve the pancreatic tail (4,5). In a recent large 5-year retrospective study, Kuza et al (6), using the National Trauma Data Bank, found pancreatic trauma to have a prevalence of 0.3%, with 61% of cases due to a blunt trauma mechanism and 39% of cases due to penetrating injury.

Teaching Point The two most important determinants of outcome following pancreatic injury are the time from injury to definitive diagnosis and the status of the main pancreatic duct (MPD) (7).
Clinical detection of pancreatic injuries can be diagnostically challenging, particularly in settings of multiorgan trauma, highlighting the integral role of imaging (8). Although specific trauma imaging protocols may vary, CT is the diagnostic imaging modality of choice for evaluating the pancreas following abdominal trauma. Provided there are no contraindications, intravenous contrast-enhanced CT, often including arterial and portal venous phase imaging, is the preferred technique (9,10). Individuals with a relatively low body fat composition pose a particular challenge in the setting of pancreatic trauma because they are at greater risk for injury from blunt trauma owing to the absence of a cushioning effect, and the paucity of intra-abdominal fat limits the detection of posttraumatic peripancreatic changes (11,12). The clinical and laboratory features of pancreatic injury may be subtle and nonspecific; they often become more conspicuous later in the postinjury course after the optimal treatment window has passed, limiting their usefulness in early management (2). CT has suboptimal sensitivity (79%) and specificity (62%) for diagnosis of MPD injuries, which is central to the grading and management of pancreatic trauma (13,14).

The outcome of pancreatic trauma is affected by complications of direct pancreatic injury and concomitant organ injury. Complications occur, especially in patients with high-grade injury, with up to one-fifth of patients developing pancreatic fistulas, intra-abdominal abscesses, wound infections, and/or pancreatic pseudocysts (13). Vascular complications, such as splenic artery pseudoaneurysm formation, can be catastrophic. Concomitant organ injuries are common with pancreatic trauma and increase morbidity and mortality, with up to 30% of deaths after pancreatic trauma caused by sepsis and multiorgan failure (15). The organ injuries commonly associated with pancreatic trauma include hepatic (47% of cases), gastric (42%), major vascular (41%), splenic (28%), renal (23%), and duodenal (19%) injuries (Fig 1) (1,16).

Spectrum of concomitant injuries commonly associated with traumatic                     pancreatic injury, depicted on axial contrast-enhanced CT images of the upper                     abdomen in three patients. (a) In the first patient, duodenal wall hematoma                     causes marked wall thickening (★) of the second duodenal segment. Edema                     and/or hemorrhage around the uncinate process could imply an American                     Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade I                     pancreatic injury. (b) Grade IV hepatic laceration, with vascular injury (arrow)                     and right adrenal hematoma (arrowhead), is depicted in a patient with surgically                     proven grade II pancreatic injury. (c) Grade III splenic laceration (arrow) is                     depicted in a patient with surgically proven grade III pancreatic                     injury.

Figure 1a. Spectrum of concomitant injuries commonly associated with traumatic pancreatic injury, depicted on axial contrast-enhanced CT images of the upper abdomen in three patients. (a) In the first patient, duodenal wall hematoma causes marked wall thickening (★) of the second duodenal segment. Edema and/or hemorrhage around the uncinate process could imply an American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade I pancreatic injury. (b) Grade IV hepatic laceration, with vascular injury (arrow) and right adrenal hematoma (arrowhead), is depicted in a patient with surgically proven grade II pancreatic injury. (c) Grade III splenic laceration (arrow) is depicted in a patient with surgically proven grade III pancreatic injury.

Spectrum of concomitant injuries commonly associated with traumatic                     pancreatic injury, depicted on axial contrast-enhanced CT images of the upper                     abdomen in three patients. (a) In the first patient, duodenal wall hematoma                     causes marked wall thickening (★) of the second duodenal segment. Edema                     and/or hemorrhage around the uncinate process could imply an American                     Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade I                     pancreatic injury. (b) Grade IV hepatic laceration, with vascular injury (arrow)                     and right adrenal hematoma (arrowhead), is depicted in a patient with surgically                     proven grade II pancreatic injury. (c) Grade III splenic laceration (arrow) is                     depicted in a patient with surgically proven grade III pancreatic                     injury.

Figure 1b. Spectrum of concomitant injuries commonly associated with traumatic pancreatic injury, depicted on axial contrast-enhanced CT images of the upper abdomen in three patients. (a) In the first patient, duodenal wall hematoma causes marked wall thickening (★) of the second duodenal segment. Edema and/or hemorrhage around the uncinate process could imply an American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade I pancreatic injury. (b) Grade IV hepatic laceration, with vascular injury (arrow) and right adrenal hematoma (arrowhead), is depicted in a patient with surgically proven grade II pancreatic injury. (c) Grade III splenic laceration (arrow) is depicted in a patient with surgically proven grade III pancreatic injury.

Spectrum of concomitant injuries commonly associated with traumatic                     pancreatic injury, depicted on axial contrast-enhanced CT images of the upper                     abdomen in three patients. (a) In the first patient, duodenal wall hematoma                     causes marked wall thickening (★) of the second duodenal segment. Edema                     and/or hemorrhage around the uncinate process could imply an American                     Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade I                     pancreatic injury. (b) Grade IV hepatic laceration, with vascular injury (arrow)                     and right adrenal hematoma (arrowhead), is depicted in a patient with surgically                     proven grade II pancreatic injury. (c) Grade III splenic laceration (arrow) is                     depicted in a patient with surgically proven grade III pancreatic                     injury.

Figure 1c. Spectrum of concomitant injuries commonly associated with traumatic pancreatic injury, depicted on axial contrast-enhanced CT images of the upper abdomen in three patients. (a) In the first patient, duodenal wall hematoma causes marked wall thickening (★) of the second duodenal segment. Edema and/or hemorrhage around the uncinate process could imply an American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) grade I pancreatic injury. (b) Grade IV hepatic laceration, with vascular injury (arrow) and right adrenal hematoma (arrowhead), is depicted in a patient with surgically proven grade II pancreatic injury. (c) Grade III splenic laceration (arrow) is depicted in a patient with surgically proven grade III pancreatic injury.

Accurate diagnosis, injury classification, and optimal management of pancreatic trauma are challenging, requiring the efforts of an astute imager working with a multidisciplinary trauma team. This relatively uncommon condition must be quickly and accurately diagnosed and treated, as implementation of surgical management within 24 hours can decrease mortality (11,17). Identification of subtle radiologic findings and use of multimodality imaging may be necessary. Delayed diagnosis may result in mortality rates that are significantly higher than the cited range of 17%–21% (13,18). In this review of traumatic pancreatic injuries, we describe the relevant anatomy, mechanisms, clinical features, complications, multimodality imaging evaluation, and AAST-OIS grading of these injuries. In addition, the various management options for these injuries are discussed.

Anatomic Considerations

The pancreas is an accessory digestive gland with important exocrine and endocrine functions. It is located in the anterior pararenal space of the abdominal retroperitoneum (Fig 2) (19,20). The pancreas courses obliquely in the coronal plane, crossing the bodies of the L1 and L2 vertebrae. This anatomic relationship contributes to pancreatic injury by way of direct blows to the epigastrium that cause anteroposterior compression (12,20,21). In the setting of trauma, fluid and/or hemorrhage in the anterior pararenal space should raise suspicion for pancreatic injury.

Pancreatic anatomy. The pancreas is located in the anterior pararenal                     space (pink) of the abdominal retroperitoneum, a space bounded by the posterior                     parietal peritoneum ventrally (arrow) and the anterior renal fascia dorsally                     (arrowhead). In the setting of trauma, fluid and/or hemorrhage in the anterior                     pararenal space should raise suspicion for pancreatic injury.

Figure 2. Pancreatic anatomy. The pancreas is located in the anterior pararenal space (pink) of the abdominal retroperitoneum, a space bounded by the posterior parietal peritoneum ventrally (arrow) and the anterior renal fascia dorsally (arrowhead). In the setting of trauma, fluid and/or hemorrhage in the anterior pararenal space should raise suspicion for pancreatic injury.

The pancreas is divided into four anatomic sections: head, neck, body, and tail (19,20). The head is the expanded part of the gland located within the C-shaped duodenum, with its uncinate process projecting posterior to the superior mesenteric vessels. The pancreatic neck is a narrow region of parenchyma overlying the portal vein–superior mesenteric vein (SMV) confluence, separating the pancreatic head from the body. Although the distinction between the pancreatic body and pancreatic tail is not well defined, it has been suggested that the separating border be designated as one-half the distance between the neck and tip of the pancreatic tail (21).

Given the central location of the pancreas, coexisting injuries are common. Anatomic relationships predict the likelihood of associated injuries: the duodenum and inferior vena cava (pancreatic head), superior mesenteric vessels (pancreatic head and uncinate process), and stomach and splenic vessels (pancreatic body and tail). Because the MPD passes through the entire pancreas, it is susceptible to injury with damage to any anatomic region of the pancreas (22).

Mechanisms of Injury

As described, the anatomic location of the pancreas contributes to the low rate of injury; this organ is relatively protected by its deep retroperitoneal location and surrounding organs (1,22). Most blunt injuries are caused by deep anterior to posterior intrusive forces compressing the pancreas against the spine, as evidenced by most injuries occurring in the pancreatic body (12). In adults, steering wheel injuries or lap belt injuries from cranial malpositioning (Fig 3a) are common. Handlebar injuries (Fig 3b) and nonaccidental trauma are relatively unique to the pediatric population (23,24). In penetrating trauma, the tract and depth of penetration often predict the likelihood of pancreatic injury (25).

Common mechanisms of pancreatic injury. (a) Cranial positioning of the                     seat belt above the pelvic bone exposes the abdominal contents to forces of                     rapid deceleration and can result in crush injury of the pancreas. (b) Sudden                     deceleration and direct focal blunt trauma to the upper abdomen by a handlebar                     represent a classic injury pattern in the pediatric population.

Figure 3a. Common mechanisms of pancreatic injury. (a) Cranial positioning of the seat belt above the pelvic bone exposes the abdominal contents to forces of rapid deceleration and can result in crush injury of the pancreas. (b) Sudden deceleration and direct focal blunt trauma to the upper abdomen by a handlebar represent a classic injury pattern in the pediatric population.

Common mechanisms of pancreatic injury. (a) Cranial positioning of the                     seat belt above the pelvic bone exposes the abdominal contents to forces of                     rapid deceleration and can result in crush injury of the pancreas. (b) Sudden                     deceleration and direct focal blunt trauma to the upper abdomen by a handlebar                     represent a classic injury pattern in the pediatric population.

Figure 3b. Common mechanisms of pancreatic injury. (a) Cranial positioning of the seat belt above the pelvic bone exposes the abdominal contents to forces of rapid deceleration and can result in crush injury of the pancreas. (b) Sudden deceleration and direct focal blunt trauma to the upper abdomen by a handlebar represent a classic injury pattern in the pediatric population.

Clinical Features

Identification of pancreatic injury is often diagnostically challenging owing to nonspecific clinical manifestations and the presence of potentially confounding concomitant injuries. Physical examination findings such as the seat belt sign (Fig 4) and flank hematoma may be present, but they are not specific (3). Furthermore, laboratory results, such as serum amylase levels, may be normal in the acute setting (11). Fever, upper abdominal pain, and leukocytosis can be associated with pancreatic injury. However, these are nonspecific signs, and, thus, their absence does not reliably exclude injury (1,12,26). As a result, the diagnosis relies heavily on imaging findings and suspicion for possible injury at initial CT. The radiologist should suggest follow-up laboratory tests or further imaging if the imaging findings indicate possible pancreatic injury.

Seat belt sign. (a) Photograph shows the seat belt sign (arrows), a                     pattern of ecchymosis on the chest and/or abdominal wall corresponding to the                     position of the diagonal or horizontal strap of the fastened seat belt. (b)                     Axial CT image shows stranding and increased attenuation (arrows) of the                     subcutaneous fat.

Figure 4a. Seat belt sign. (a) Photograph shows the seat belt sign (arrows), a pattern of ecchymosis on the chest and/or abdominal wall corresponding to the position of the diagonal or horizontal strap of the fastened seat belt. (b) Axial CT image shows stranding and increased attenuation (arrows) of the subcutaneous fat.

Seat belt sign. (a) Photograph shows the seat belt sign (arrows), a                     pattern of ecchymosis on the chest and/or abdominal wall corresponding to the                     position of the diagonal or horizontal strap of the fastened seat belt. (b)                     Axial CT image shows stranding and increased attenuation (arrows) of the                     subcutaneous fat.

Figure 4b. Seat belt sign. (a) Photograph shows the seat belt sign (arrows), a pattern of ecchymosis on the chest and/or abdominal wall corresponding to the position of the diagonal or horizontal strap of the fastened seat belt. (b) Axial CT image shows stranding and increased attenuation (arrows) of the subcutaneous fat.

Imaging Techniques and Evaluation

Teaching Point Imaging has a vital role in the diagnosis and management of pancreatic injuries, given the nonspecific clinical findings. A multimodality approach is often required: Contrast-enhanced CT serves as the initial imaging modality, and MR cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) serves as a problem-solving modality in hemodynamically stable patients for whom there is no immediate indication for laparotomy, to assess MPD integrity (Fig 5).

Diagram of the imaging pathway for pancreatic trauma. Hemodynamically                     unstable patients proceed directly to exploratory laparotomy, bypassing imaging                     evaluation. Patients who undergo damage-control laparotomy may need to undergo                     contrast-enhanced CT (CECT) afterward. For hemodynamically stable patients,                     contrast-enhanced CT is the initial modality of choice. MRCP and/or ERCP serves                     as a problem-solving modality, primarily for evaluation of the integrity of the                     MPD in hemodynamically stable patients who have no other indication for urgent                     exploratory laparotomy, such as bowel or hollow viscus perforation.

Figure 5. Diagram of the imaging pathway for pancreatic trauma. Hemodynamically unstable patients proceed directly to exploratory laparotomy, bypassing imaging evaluation. Patients who undergo damage-control laparotomy may need to undergo contrast-enhanced CT (CECT) afterward. For hemodynamically stable patients, contrast-enhanced CT is the initial modality of choice. MRCP and/or ERCP serves as a problem-solving modality, primarily for evaluation of the integrity of the MPD in hemodynamically stable patients who have no other indication for urgent exploratory laparotomy, such as bowel or hollow viscus perforation.

Computed Tomography

For hemodynamically stable patients, contrast-enhanced CT is the initial step in the pancreatic trauma imaging pathway. CT remains the primary initial imaging modality of choice for patients with blunt or penetrating trauma, as it facilitates rapid image acquisition with near-isotropic voxels. This acquisition permits the construction of multiplanar reformatted images, which are particularly valuable in evaluating for MPD injury (27). Using the appropriate techniques for image acquisition and contrast material administration optimizes the detection of pancreatic injuries and any additional abdominal injuries. It is important to minimize the radiation dose delivered without compromising image quality or diagnostic evaluation (28). Although scanner technology varies widely among institutions, it is common to acquire primary axial 0.6–2.5-mm-thick images with a pitch of 1.0–1.8 (1).

Before undergoing scanning, all patients being assessed for trauma should receive an intravenous bolus (100–150 mL [350 mg of iodine per milliliter; total iodine load, 35.0–52.5 g]) of contrast material, injected at 3–5 mL per second via an 18- or 20-gauge cannula. Ideally, the cannula would be placed in a large peripheral vein (28). With use of a dual-syringe power injector, the contrast material injection can be immediately followed by a 30–70-mL saline bolus injected at 3–5 mL per second. The use of oral contrast material contributes to a delay in CT scanning and is not used in patients with blunt trauma; however, its use in the setting of penetrating trauma remains controversial (5,28).

Historically, the standard trauma protocol has included a portal venous phase abdominal and pelvic CT sequence performed 65–80 seconds after the administration of contrast material (28). Many institutions have recently added arterial phase imaging to evaluate for arterial vascular injury (9). The mean attenuation value for the pancreatic parenchyma peaks (82.1–85.2 HU) at 35–45 seconds after the start of the injection (29). Peak pancreatic arterial attenuation and venous attenuation occur at 25–40 seconds and 55–60 seconds, respectively (29).

Although adjusting the acquisition time to allow peak enhancement of the pancreas may improve detection of pancreatic injury, it is not recommended, given the possibility of limiting diagnostic accuracy and efficiency in detection of other organ injuries. However, including the pancreatic parenchymal phase at follow-up CT may be beneficial for detecting subtle injuries (1). In addition to portal venous phase imaging, delayed phase imaging can be performed at 2–3 minutes after the contrast material injection in cases of suspected active hemorrhage, including active bleeding from the pancreas (1). Some trauma center clinicians interpret studies while the patient remains on the CT table, and in these cases, the radiologist may recommend the acquisition of delayed phase images on the basis of findings seen during real-time interpretation.

Although MRCP and ERCP have higher diagnostic accuracy than does CT for evaluation of the MPD, advancements in CT technology and postprocessing techniques have led to improved direct CT assessment of the MPD (30). Using thin-section imaging (0.5-mm axial images) in combination with multiplanar reformatted images, Itoh et al (31) reported MPD depiction rates of 94%–95% in the head, neck, and body and of 75% in the tail. Curved planar reformatted (32) and minimum intensity projection (33) images also have shown promise for improving MPD visualization. The smallest pixel value for the path of a ray cast through a slab of images, potentially improving the assessment of low-attenuation structures such as the MPD, has been recorded for minimum intensity projection images (34).

With dual-energy CT, data are acquired by using two different energy spectra, which commonly include a low-energy (80- or 100-kVp) level and a high-energy (140-kVp) level (35). The benefits of dual-energy CT, as compared with monoenergetic multidetector CT, include an improved iodine contrast-to-noise ratio (35), the ability to analyze tissues and materials that have different attenuation properties, and the ability to create a virtual nonenhanced image set. Given that use of low–kilovolt-peak and low-kiloelectron images have been shown to improve visualization of the pancreatic duct and hypovascular pancreatic masses, dual-energy CT may help to improve detection of pancreatic lacerations and pancreatic duct involvement (36).

MRI/MRCP

In the setting of pancreatic trauma, combined MRI and MRCP (MRI/MRCP) is used as a problem-solving tool for noninvasive assessment of MPD integrity or to better define parenchymal injury, typically in hemodynamically stable patients who have equivocal CT findings or negative initial CT findings but high clinical suspicion for pancreatic injury. MRCP can depict the MPD in the pancreatic body in up to 97% of cases and in the pancreatic tail in up to 83% of cases (12). Secretin-stimulated MRCP can depict not only MPD injury but also continued leakage from the MPD, including leaks beyond areas of obstruction that cannot be assessed with ERCP (37).

Compared with ERCP, MRI/MRCP enables evaluation of the MPD upstream of a laceration and is noninvasive, typically more readily available, faster, and more accurate for delineation of pancreatic parenchymal injury and identification of fluid collections upstream of the site of MPD transection (12,38). If an MPD injury is present, MRCP can assist in directing ERCP-guided therapy (12).

Free-breathing MRI is useful for patients who may not be able to hold their breath for an extended period or comply with technologist directions owing to intubation or sedation (39,40). With free-breathing protocols, the most reproducible position is that at end expiration (41). In addition, respiratory motion triggering can be used to minimize breathing artifacts (40). Magnetization-prepared T1-weighted MRI sequences and single-excitation half-Fourier T2-weighted MRI sequences are the mainstay of free-breathing imaging protocols (41). Of relevance in pancreatic trauma, T2-weighted MR images obtained with a half-Fourier single-shot spin-echo sequence provide excellent depiction of the pancreaticobiliary tree (41).

The MRI/MRCP protocol commonly used includes acquisition of axial T1- and T2-weighted MR images, an axial and coronal fast spoiled gradient-echo imaging with steady-state free precession and single-shot fast spin-echo T2-weighted MRI sequence, and heavily T2-weighted three-dimensional MRI sequences for MRCP. Contrast-enhanced T1-weighted fat-saturated MRI also may aid in delineating pancreatic parenchymal injuries and associated fluid collections.

ERCP-based Diagnosis

ERCP is considered the most accurate diagnostic tool for MPD evaluation (12,28,42). This imaging examination involves the advancement of a duodenoscope from the oropharynx to the second part of the duodenum to directly visualize the major papilla. Once a cannula is inserted into the major papilla and MPD via a catheter, contrast material is injected under fluoroscopic guidance (43). Ductal injury is confirmed at ERCP with evidence of abrupt MPD termination or contrast material extravasation (Fig 6).

Injuries in a 43-year-old man involved in a high-speed motor vehicle                         collision. (a) Axial contrast-enhanced abdominal CT image shows a pancreatic                         neck fracture, a large intrapancreatic hematoma with active contrast                         material extravasation (arrowhead), and a large amount of hyperattenuating                         peripancreatic fluid. (b) ERCP image shows moderate contrast material                         extravasation (between arrows). No filling of the MPD was                         observed.

Figure 6a. Injuries in a 43-year-old man involved in a high-speed motor vehicle collision. (a) Axial contrast-enhanced abdominal CT image shows a pancreatic neck fracture, a large intrapancreatic hematoma with active contrast material extravasation (arrowhead), and a large amount of hyperattenuating peripancreatic fluid. (b) ERCP image shows moderate contrast material extravasation (between arrows). No filling of the MPD was observed.

Injuries in a 43-year-old man involved in a high-speed motor vehicle                         collision. (a) Axial contrast-enhanced abdominal CT image shows a pancreatic                         neck fracture, a large intrapancreatic hematoma with active contrast                         material extravasation (arrowhead), and a large amount of hyperattenuating                         peripancreatic fluid. (b) ERCP image shows moderate contrast material                         extravasation (between arrows). No filling of the MPD was                         observed.

Figure 6b. Injuries in a 43-year-old man involved in a high-speed motor vehicle collision. (a) Axial contrast-enhanced abdominal CT image shows a pancreatic neck fracture, a large intrapancreatic hematoma with active contrast material extravasation (arrowhead), and a large amount of hyperattenuating peripancreatic fluid. (b) ERCP image shows moderate contrast material extravasation (between arrows). No filling of the MPD was observed.

The major advantage of ERCP, as compared with MRCP, is the capability for direct image-guided intervention in hemodynamically stable patients (12,28,42). In the presence of MPD injury, ERCP can be used for stent placement. It can also assist in the management of MPD injury–related late complications (eg, pseudocyst and fistulas) and enable transpapillary and transmural drainage (42). Delays in ERCP-guided stent placement (>72 hours after the initial trauma) can lead to increased rates of complications (12).

Imaging Findings

Terminology and Definitions

The most widely used system for classification of traumatic organ injury is the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) system. This classification was first published in 1989 and was updated in 1994, with iterative updates regarding certain organs issued as recently as 2018 (44,45). Pancreatic injury is stratified according to severity by using the injury type (hematoma or laceration), injury location (head, body, or tail), and presence or absence of MPD injury (46). The terminology for describing pancreatic trauma is summarized in Table 1. In the AAST-OIS classification, the pancreas is divided into proximal and distal components relative to the SMV–portal vein axis. The proximal pancreas is defined as the parenchyma to the right of the SMV–portal vein axis, while the distal pancreas refers to the parenchyma to the left of this axis (Fig 7).

Table 1: Definitions and CT Findings of Pancreatic Injuries

Table 1:
AAST-OIS classification of pancreatic injury location. Drawing (a) and                         coronal contrast-enhanced CT image (b) depict the proximal and distal                         components of the pancreas, which are used to classify pancreatic traumatic                         injuries. The component to the right of the portal vein–SMV axis                         (arrow) is designated the proximal pancreas (outlined in red), and the                         component to the left of the axis is designated the distal pancreas                         (outlined in green).

Figure 7a. AAST-OIS classification of pancreatic injury location. Drawing (a) and coronal contrast-enhanced CT image (b) depict the proximal and distal components of the pancreas, which are used to classify pancreatic traumatic injuries. The component to the right of the portal vein–SMV axis (arrow) is designated the proximal pancreas (outlined in red), and the component to the left of the axis is designated the distal pancreas (outlined in green).

AAST-OIS classification of pancreatic injury location. Drawing (a) and                         coronal contrast-enhanced CT image (b) depict the proximal and distal                         components of the pancreas, which are used to classify pancreatic traumatic                         injuries. The component to the right of the portal vein–SMV axis                         (arrow) is designated the proximal pancreas (outlined in red), and the                         component to the left of the axis is designated the distal pancreas                         (outlined in green).

Figure 7b. AAST-OIS classification of pancreatic injury location. Drawing (a) and coronal contrast-enhanced CT image (b) depict the proximal and distal components of the pancreas, which are used to classify pancreatic traumatic injuries. The component to the right of the portal vein–SMV axis (arrow) is designated the proximal pancreas (outlined in red), and the component to the left of the axis is designated the distal pancreas (outlined in green).

The location of the pancreatic injury affects the prognosis. Proximal injuries have higher mortality rates than do distal injuries, probably owing to associated vascular involvement (12,47). It is important to recognize that using the terms proximal and distal when describing pancreatic injuries can lead to ambiguity, as the pancreas is an endocrine and exocrine organ that produces enzymes that drain from the tail to the head. A study by Khara et al (48) involving multiple physician specialties (including radiology, surgery, and gastroenterology) showed a nearly 50–50 split in identification of the proximal and distal pancreas. Given the ambiguous terminology, with significant discordance among physician providers across medical and surgical disciplines, to minimize potential errors, it is recommended that the injured portion of the pancreas be specifically labeled as the head, body, or tail, or with specific designation of the injury as to the right or to the left of the portal vein–SMV axis.

Direct and Indirect Imaging Findings

The traumatized pancreas can appear normal on initially obtained CT images, particularly within the first 12 hours after the injury, and repeat imaging at 24 hours may be warranted when clinical suspicion is high. At imaging, there are direct and indirect findings of pancreatic injury (Table 1). Direct signs of pancreatic injury at CT include laceration, focal pancreatic enlargement, and pancreatic hematoma. Parenchymal contusion appears as an indistinct area of hypoenhancement with peripancreatic edema, while lacerations are sharply defined with a linear or branching configuration of low attenuation, indicating parenchymal tear. Lacerations can be superficial (extending through <50% of pancreatic tissue thickness), deep (>50% of tissue thickness), or complete (extending through entire gland). Complete laceration constitutes pancreatic transection or fracture (8).

Tissue loss refers to a region of pancreatic destruction with loss of identifiable pancreatic architecture. Regions of tissue loss can demonstrate heterogeneously decreased enhancement secondary to disruption of the microvascular supply, and hemorrhagic edema. Indirect CT signs of pancreatic injury include nonspecific peripancreatic fluid (such as fluid in the lesser sac or interdigitating between the pancreas and spleen), induration of the peripancreatic fat, and thickening of the left anterior renal fascia (8).

AAST-OIS Pancreatic Injury Grading

Teaching Point For standard communication with trauma surgeons, radiologists should synthesize the imaging findings to determine and report an injury grade. In the AAST-OIS classification system, there are five grades (I–V) of pancreatic injury (Fig 8, Table 2). The key distinction between low-grade (AAST-OIS grades I and II) and high-grade (AAST-OIS grades III–V) pancreatic injuries is involvement of the MPD. Although associated vascular injury and active vascular contrast material extravasation are not included in the current AAST-OIS classification, these findings are vital to determining patient management and predicting outcomes and must be reported in a timely fashion.

AAST-OIS pancreas injury grades. Grade I: minor contusion without                         ductal injury, or superficial laceration without ductal injury. Grade II:                         major contusion without ductal injury or tissue loss, or major laceration                         without ductal injury or tissue loss. Grade III: distal transection or                         parenchymal injury with ductal injury. Grade IV: proximal transection or                         parenchymal injury involving the ampulla. Grade V: massive disruption of the                         pancreatic head.

Figure 8. AAST-OIS pancreas injury grades. Grade I: minor contusion without ductal injury, or superficial laceration without ductal injury. Grade II: major contusion without ductal injury or tissue loss, or major laceration without ductal injury or tissue loss. Grade III: distal transection or parenchymal injury with ductal injury. Grade IV: proximal transection or parenchymal injury involving the ampulla. Grade V: massive disruption of the pancreatic head.

Table 2: AAST-OIS Grading of Pancreatic Trauma

Table 2:

Grade I.—An AAST-OIS grade I pancreatic injury is defined as a superficial laceration or minor contusion without MPD injury. Pancreatic hypoenhancement from contusions may not be visible owing to the timing of single-phase contrast-enhanced CT, and it may be more conspicuous on multiphase (arterial and portal venous) studies. CT findings can be delayed, with approximately 20%–40% of parenchymal injuries being occult at CT performed within 12 hours after the injury (42). In contrast, peripancreatic edema is almost always present with pancreatic contusion. Therefore, the possibility of pancreatic contusion should be raised when peripancreatic edema is present, even if pancreatic hypoenhancement is absent (Fig 9). Given that injury to surrounding structures, such as the liver and spleen, is common in pancreatic trauma, it may be difficult to attribute the source of peripancreatic fluid specifically to the pancreas. In such cases, correlation with pancreatic enzyme levels may be helpful. The AAST-OIS group advises advancing the injury grade by one grade in cases of more than one discrete injury grade, without exceeding grade III, as the presence of two grade I injuries would represent a grade II organ injury and a combination of grade I and grade II injuries would constitute a grade III injury. For multiple grade III or higher injuries, a mixed injury pattern should be assigned on the basis of the most severe component. Early imaging findings often underestimate the extent of injury, and follow-up CT or MRI performed within 24–48 hours is recommended if upgrading the injury will alter the clinical management (38).

AAST-OIS grade I pancreatic injury, a minor contusion, in a                         51-year-old man after a motor vehicle collision. Axial contrast-enhanced CT                         images obtained at different levels show mild stranding adjacent to the                         pancreatic uncinate process and in the left anterior pararenal space                         (arrow), suggesting minor pancreatic contusion without a visible focal                         parenchymal abnormality. The peripancreatic fluid is a combination of                         hemorrhage and edema. The possibility of pancreatic contusion should be                         raised when peripancreatic edema is present, even if pancreatic                         hypoenhancement is absent. This patient had elevated pancreatic enzyme                         levels.

Figure 9a. AAST-OIS grade I pancreatic injury, a minor contusion, in a 51-year-old man after a motor vehicle collision. Axial contrast-enhanced CT images obtained at different levels show mild stranding adjacent to the pancreatic uncinate process and in the left anterior pararenal space (arrow), suggesting minor pancreatic contusion without a visible focal parenchymal abnormality. The peripancreatic fluid is a combination of hemorrhage and edema. The possibility of pancreatic contusion should be raised when peripancreatic edema is present, even if pancreatic hypoenhancement is absent. This patient had elevated pancreatic enzyme levels.

AAST-OIS grade I pancreatic injury, a minor contusion, in a                         51-year-old man after a motor vehicle collision. Axial contrast-enhanced CT                         images obtained at different levels show mild stranding adjacent to the                         pancreatic uncinate process and in the left anterior pararenal space                         (arrow), suggesting minor pancreatic contusion without a visible focal                         parenchymal abnormality. The peripancreatic fluid is a combination of                         hemorrhage and edema. The possibility of pancreatic contusion should be                         raised when peripancreatic edema is present, even if pancreatic                         hypoenhancement is absent. This patient had elevated pancreatic enzyme                         levels.

Figure 9b. AAST-OIS grade I pancreatic injury, a minor contusion, in a 51-year-old man after a motor vehicle collision. Axial contrast-enhanced CT images obtained at different levels show mild stranding adjacent to the pancreatic uncinate process and in the left anterior pararenal space (arrow), suggesting minor pancreatic contusion without a visible focal parenchymal abnormality. The peripancreatic fluid is a combination of hemorrhage and edema. The possibility of pancreatic contusion should be raised when peripancreatic edema is present, even if pancreatic hypoenhancement is absent. This patient had elevated pancreatic enzyme levels.

AAST-OIS grade I pancreatic injury, a minor contusion, in a                         51-year-old man after a motor vehicle collision. Axial contrast-enhanced CT                         images obtained at different levels show mild stranding adjacent to the                         pancreatic uncinate process and in the left anterior pararenal space                         (arrow), suggesting minor pancreatic contusion without a visible focal                         parenchymal abnormality. The peripancreatic fluid is a combination of                         hemorrhage and edema. The possibility of pancreatic contusion should be                         raised when peripancreatic edema is present, even if pancreatic                         hypoenhancement is absent. This patient had elevated pancreatic enzyme                         levels.

Figure 9c. AAST-OIS grade I pancreatic injury, a minor contusion, in a 51-year-old man after a motor vehicle collision. Axial contrast-enhanced CT images obtained at different levels show mild stranding adjacent to the pancreatic uncinate process and in the left anterior pararenal space (arrow), suggesting minor pancreatic contusion without a visible focal parenchymal abnormality. The peripancreatic fluid is a combination of hemorrhage and edema. The possibility of pancreatic contusion should be raised when peripancreatic edema is present, even if pancreatic hypoenhancement is absent. This patient had elevated pancreatic enzyme levels.

Grade II.—A grade II pancreatic injury is defined as a major laceration or contusion without MPD injury. While the distinction between minor injury and major injury is not well established, major laceration is usually considered when the injury involves 25%–50% of the pancreatic depth (Fig 10). Greater than 50% of the pancreatic depth implies an MPD injury and a higher pancreatic injury grade (grade III–V). However, this approach is limited in the pancreatic head, a site at which the pancreatic duct is tortuous and may not lie at the center of the parenchyma (47). Major contusion is considered when there is hypoenhancement involving greater than 25% of the pancreatic parenchyma.

AAST-OIS grade II pancreatic injury, a major laceration, in a                         28-year-old man with a close-range low-caliber gunshot wound in the left                         upper abdomen. He was hemodynamically stable with an oozing entrance wound                         in the left upper quadrant. (a) Axial contrast-enhanced CT image shows an                         apparent nearly full-thickness laceration (arrow) in the pancreatic tail.                         (b) Coronal contrast-enhanced CT image shows that this laceration traverses                         only the inferior aspect of the pancreas, sparing the MPD (arrow). (c)                         Magnified CT images show the laceration (dashed line) and pancreas (solid                         line). Peripancreatic and perirenal retroperitoneal hemorrhage (☆ in                         a–c) is seen.

Figure 10a. AAST-OIS grade II pancreatic injury, a major laceration, in a 28-year-old man with a close-range low-caliber gunshot wound in the left upper abdomen. He was hemodynamically stable with an oozing entrance wound in the left upper quadrant. (a) Axial contrast-enhanced CT image shows an apparent nearly full-thickness laceration (arrow) in the pancreatic tail. (b) Coronal contrast-enhanced CT image shows that this laceration traverses only the inferior aspect of the pancreas, sparing the MPD (arrow). (c) Magnified CT images show the laceration (dashed line) and pancreas (solid line). Peripancreatic and perirenal retroperitoneal hemorrhage (☆ in a–c) is seen.

AAST-OIS grade II pancreatic injury, a major laceration, in a                         28-year-old man with a close-range low-caliber gunshot wound in the left                         upper abdomen. He was hemodynamically stable with an oozing entrance wound                         in the left upper quadrant. (a) Axial contrast-enhanced CT image shows an                         apparent nearly full-thickness laceration (arrow) in the pancreatic tail.                         (b) Coronal contrast-enhanced CT image shows that this laceration traverses                         only the inferior aspect of the pancreas, sparing the MPD (arrow). (c)                         Magnified CT images show the laceration (dashed line) and pancreas (solid                         line). Peripancreatic and perirenal retroperitoneal hemorrhage (☆ in                         a–c) is seen.

Figure 10b. AAST-OIS grade II pancreatic injury, a major laceration, in a 28-year-old man with a close-range low-caliber gunshot wound in the left upper abdomen. He was hemodynamically stable with an oozing entrance wound in the left upper quadrant. (a) Axial contrast-enhanced CT image shows an apparent nearly full-thickness laceration (arrow) in the pancreatic tail. (b) Coronal contrast-enhanced CT image shows that this laceration traverses only the inferior aspect of the pancreas, sparing the MPD (arrow). (c) Magnified CT images show the laceration (dashed line) and pancreas (solid line). Peripancreatic and perirenal retroperitoneal hemorrhage (☆ in a–c) is seen.

AAST-OIS grade II pancreatic injury, a major laceration, in a                         28-year-old man with a close-range low-caliber gunshot wound in the left                         upper abdomen. He was hemodynamically stable with an oozing entrance wound                         in the left upper quadrant. (a) Axial contrast-enhanced CT image shows an                         apparent nearly full-thickness laceration (arrow) in the pancreatic tail.                         (b) Coronal contrast-enhanced CT image shows that this laceration traverses                         only the inferior aspect of the pancreas, sparing the MPD (arrow). (c)                         Magnified CT images show the laceration (dashed line) and pancreas (solid                         line). Peripancreatic and perirenal retroperitoneal hemorrhage (☆ in                         a–c) is seen.

Figure 10c. AAST-OIS grade II pancreatic injury, a major laceration, in a 28-year-old man with a close-range low-caliber gunshot wound in the left upper abdomen. He was hemodynamically stable with an oozing entrance wound in the left upper quadrant. (a) Axial contrast-enhanced CT image shows an apparent nearly full-thickness laceration (arrow) in the pancreatic tail. (b) Coronal contrast-enhanced CT image shows that this laceration traverses only the inferior aspect of the pancreas, sparing the MPD (arrow). (c) Magnified CT images show the laceration (dashed line) and pancreas (solid line). Peripancreatic and perirenal retroperitoneal hemorrhage (☆ in a–c) is seen.

Grade III.—A grade III pancreatic injury is defined as a deep pancreatic laceration with MPD injury or distal pancreatic transection (occurring to the left of the SMV–portal vein axis) (Fig 11) (46). In addition, a grade III injury may be diagnosed on the basis of a combination of separate grade I and grade II injuries, as the AAST-OIS group recommends advancing one injury grade for multiple injuries up to grade III. Because mortality can be as high as 30% in patients with MPD involvement and worsens with delays in diagnosis, rapid and accurate diagnosis and treatment are essential (1,4951). Injury to the MPD may be difficult to identify on CT images, and when a pancreatic parenchymal laceration is identified, careful scrutiny of the laceration should be performed in the axial, sagittal, and coronal planes to evaluate for injury on both sides of the MPD. A laceration on both sides of the MPD (>50% of parenchymal thickness) confirmed on multiplanar images implies an MPD injury.

AAST-OIS grade III pancreatic injury, a distal transection, in a                         28-year-old male pedestrian in a pedestrian versus motor vehicle collision.                         (a) Axial contrast-enhanced CT image shows near-complete transection of the                         distal pancreas (dashed line), with a significant amount of surrounding                         blood products (☆), including blood in the right hepatorenal fossa                         (arrowhead). This is a deep laceration extending more than 50% of the                         parenchymal thickness (confirmed on multiplanar reformatted images),                         implying a ductal injury. (b) Coronal contrast-enhanced CT image shows sharp                         demarcation of the distal pancreas, beyond which there is hypoenhancement                         (arrow). A large hematoma superior to the pancreas (☆) and a focus of                         active contrast material extravasation (arrowhead) are seen.

Figure 11a. AAST-OIS grade III pancreatic injury, a distal transection, in a 28-year-old male pedestrian in a pedestrian versus motor vehicle collision. (a) Axial contrast-enhanced CT image shows near-complete transection of the distal pancreas (dashed line), with a significant amount of surrounding blood products (☆), including blood in the right hepatorenal fossa (arrowhead). This is a deep laceration extending more than 50% of the parenchymal thickness (confirmed on multiplanar reformatted images), implying a ductal injury. (b) Coronal contrast-enhanced CT image shows sharp demarcation of the distal pancreas, beyond which there is hypoenhancement (arrow). A large hematoma superior to the pancreas (☆) and a focus of active contrast material extravasation (arrowhead) are seen.

AAST-OIS grade III pancreatic injury, a distal transection, in a                         28-year-old male pedestrian in a pedestrian versus motor vehicle collision.                         (a) Axial contrast-enhanced CT image shows near-complete transection of the                         distal pancreas (dashed line), with a significant amount of surrounding                         blood products (☆), including blood in the right hepatorenal fossa                         (arrowhead). This is a deep laceration extending more than 50% of the                         parenchymal thickness (confirmed on multiplanar reformatted images),                         implying a ductal injury. (b) Coronal contrast-enhanced CT image shows sharp                         demarcation of the distal pancreas, beyond which there is hypoenhancement                         (arrow). A large hematoma superior to the pancreas (☆) and a focus of                         active contrast material extravasation (arrowhead) are seen.

Figure 11b. AAST-OIS grade III pancreatic injury, a distal transection, in a 28-year-old male pedestrian in a pedestrian versus motor vehicle collision. (a) Axial contrast-enhanced CT image shows near-complete transection of the distal pancreas (dashed line), with a significant amount of surrounding blood products (☆), including blood in the right hepatorenal fossa (arrowhead). This is a deep laceration extending more than 50% of the parenchymal thickness (confirmed on multiplanar reformatted images), implying a ductal injury. (b) Coronal contrast-enhanced CT image shows sharp demarcation of the distal pancreas, beyond which there is hypoenhancement (arrow). A large hematoma superior to the pancreas (☆) and a focus of active contrast material extravasation (arrowhead) are seen.

If CT findings are equivocal, MRI/MRCP can be used to further define the parenchymal injuries, evaluate MPD integrity, and confirm the injury grade (52,53). According to the 2019 World Society of Emergency Surgery guidelines (53), contrast-enhanced CT should be performed in hemodynamically stable patients, with follow-up CT in 12–24 hours considered when there is high suspicion for MPD injury with negative initial CT results.

Grade IV.—Injuries to the proximal pancreas that involve the MPD are considered to be grade IV injuries (Fig 12). A grade IV injury is defined as proximal transection or parenchymal injury involving the ampulla (46). Compared with distal pancreatic injuries, proximal pancreatic injuries are associated with a worse prognosis and higher mortality rates. Poor outcomes of higher-grade injuries are likely to be due to concomitant vascular injuries, the high likelihood of additional solid organ and hollow viscus injuries, and the anatomy of the proximal pancreas (ie, its intimate relationship with the vital mesenteric root vasculature, ampulla, distal common bile duct, and second portion of the duodenum), limiting surgical and other treatment options (1,54,55). Detection of compromise to the MPD in grade IV injuries may be challenging for the radiologist during the initial imaging evaluation and often requires secondary findings or additional imaging studies.

AAST-OIS grade IV pancreatic injury. Axial contrast-enhanced CT images                         of the upper abdomen obtained at different levels, from cranial (a) to                         caudal (c), show transversely oriented transection through the pancreatic                         head (arrow) with associated hemorrhage (arrowhead), including blood in the                         anterior pararenal space (☆ in b).

Figure 12a. AAST-OIS grade IV pancreatic injury. Axial contrast-enhanced CT images of the upper abdomen obtained at different levels, from cranial (a) to caudal (c),show transversely oriented transection through the pancreatic head (arrow) with associated hemorrhage (arrowhead), including blood in the anterior pararenal space (☆ in b).

AAST-OIS grade IV pancreatic injury. Axial contrast-enhanced CT images                         of the upper abdomen obtained at different levels, from cranial (a) to                         caudal (c),show transversely oriented transection through the pancreatic                         head (arrow) with associated hemorrhage (arrowhead), including blood in the                         anterior pararenal space (☆ in b).

Figure 12b. AAST-OIS grade IV pancreatic injury. Axial contrast-enhanced CT images of the upper abdomen obtained at different levels, from cranial (a) to caudal (c),show transversely oriented transection through the pancreatic head (arrow) with associated hemorrhage (arrowhead), including blood in the anterior pararenal space (☆ in b).

AAST-OIS grade IV pancreatic injury. Axial contrast-enhanced CT images                         of the upper abdomen obtained at different levels, from cranial (a) to                         caudal (c),show transversely oriented transection through the pancreatic                         head (arrow) with associated hemorrhage (arrowhead), including blood in the                         anterior pararenal space (☆ in b).

Figure 12c. AAST-OIS grade IV pancreatic injury. Axial contrast-enhanced CT images of the upper abdomen obtained at different levels, from cranial (a) to caudal (c),show transversely oriented transection through the pancreatic head (arrow) with associated hemorrhage (arrowhead), including blood in the anterior pararenal space (☆ in b).

At CT, grade IV injuries are depicted as deep through-and-through parenchymal lacerations that involve the pancreatic parenchyma and the MPD and are located to the left of the SMV–portal vein axis (46,54). Often, CT may not directly depict MPD injury (15). As described earlier, MPD injury can be inferred if a laceration extends more than 50% of the parenchymal depth, as confirmed on multiplanar reformatted CT images. An injury involving the ampulla may also be subtle, and these injuries are usually associated with duodenal injuries. If there is surrounding edema and hemorrhage or wall thickening of the second portion of the duodenum, it is important to closely evaluate the ampulla and pancreatic head region. MRI/MRCP, ERCP, or exploratory laparotomy may be needed for more direct assessment (1,49,54).

Grade V.—Grade V injuries are associated with the highest morbidity and mortality (2). A grade V pancreatic injury, as compared with a grade IV injury, is defined as a massive disruption in to the pancreatic head and is associated with a higher likelihood of concomitant duodenal and/or vascular injury (1,46,54,55). A grade V injury can be conceptualized as a “shattered” pancreas (Fig 13). At CT, the pancreas may demonstrate segmental devascularization due to transection of major arteries, massive tissue loss from partial or complete transection, or substantial architectural distortion. This type of injury is more common with penetrating trauma, although blunt abdominal trauma can result in high-grade injury from compression of the pancreas against the spine (1,49). Complete pancreatic rupture typically occurs near the neck of the gland, in line with the SMV–portal vein axis. Pancreatic and peripancreatic fluid collections are not uncommon on initially obtained CT scans owing to the presence of enzyme leakage, edema, and hemorrhage from high-grade MPD compromise (1).

AAST-OIS grade V injury in a 31-year-old restrained (wearing a                         seatbelt) driver after a motor vehicle collision. Axial contrast-enhanced CT                         images through the upper abdomen show a geographic region of nonenhancement                         in the pancreatic head (a), consistent with massive disruption of the                         pancreatic head (arrow in a), as well as an ill-defined region of                         mixed-attenuation soft tissue (b, c) with loss of recognizable anatomic                         features. This mixed-attenuation tissue represents a combination of                         macerated pancreatic tissue, blood products, and duodenal wall injury. Grade                         V injury is highly associated with duodenal wall injury (arrow in b) and                         additional abdominal visceral injury, such as the extensive lacerations of                         the left hepatic lobe (dashed outline) depicted in c.

Figure 13a. AAST-OIS grade V injury in a 31-year-old restrained (wearing a seatbelt) driver after a motor vehicle collision. Axial contrast-enhanced CT images through the upper abdomen show a geographic region of nonenhancement in the pancreatic head (a), consistent with massive disruption of the pancreatic head (arrow in a), as well as an ill-defined region of mixed-attenuation soft tissue (b, c) with loss of recognizable anatomic features. This mixed-attenuation tissue represents a combination of macerated pancreatic tissue, blood products, and duodenal wall injury. Grade V injury is highly associated with duodenal wall injury (arrow in b) and additional abdominal visceral injury, such as the extensive lacerations of the left hepatic lobe (dashed outline) depicted in c.

AAST-OIS grade V injury in a 31-year-old restrained (wearing a                         seatbelt) driver after a motor vehicle collision. Axial contrast-enhanced CT                         images through the upper abdomen show a geographic region of nonenhancement                         in the pancreatic head (a), consistent with massive disruption of the                         pancreatic head (arrow in a), as well as an ill-defined region of                         mixed-attenuation soft tissue (b, c) with loss of recognizable anatomic                         features. This mixed-attenuation tissue represents a combination of                         macerated pancreatic tissue, blood products, and duodenal wall injury. Grade                         V injury is highly associated with duodenal wall injury (arrow in b) and                         additional abdominal visceral injury, such as the extensive lacerations of                         the left hepatic lobe (dashed outline) depicted in c.

Figure 13b. AAST-OIS grade V injury in a 31-year-old restrained (wearing a seatbelt) driver after a motor vehicle collision. Axial contrast-enhanced CT images through the upper abdomen show a geographic region of nonenhancement in the pancreatic head (a), consistent with massive disruption of the pancreatic head (arrow in a), as well as an ill-defined region of mixed-attenuation soft tissue (b, c) with loss of recognizable anatomic features. This mixed-attenuation tissue represents a combination of macerated pancreatic tissue, blood products, and duodenal wall injury. Grade V injury is highly associated with duodenal wall injury (arrow in b) and additional abdominal visceral injury, such as the extensive lacerations of the left hepatic lobe (dashed outline) depicted in c.

AAST-OIS grade V injury in a 31-year-old restrained (wearing a                         seatbelt) driver after a motor vehicle collision. Axial contrast-enhanced CT                         images through the upper abdomen show a geographic region of nonenhancement                         in the pancreatic head (a), consistent with massive disruption of the                         pancreatic head (arrow in a), as well as an ill-defined region of                         mixed-attenuation soft tissue (b, c) with loss of recognizable anatomic                         features. This mixed-attenuation tissue represents a combination of                         macerated pancreatic tissue, blood products, and duodenal wall injury. Grade                         V injury is highly associated with duodenal wall injury (arrow in b) and                         additional abdominal visceral injury, such as the extensive lacerations of                         the left hepatic lobe (dashed outline) depicted in c.

Figure 13c. AAST-OIS grade V injury in a 31-year-old restrained (wearing a seatbelt) driver after a motor vehicle collision. Axial contrast-enhanced CT images through the upper abdomen show a geographic region of nonenhancement in the pancreatic head (a), consistent with massive disruption of the pancreatic head (arrow in a), as well as an ill-defined region of mixed-attenuation soft tissue (b, c) with loss of recognizable anatomic features. This mixed-attenuation tissue represents a combination of macerated pancreatic tissue, blood products, and duodenal wall injury. Grade V injury is highly associated with duodenal wall injury (arrow in b) and additional abdominal visceral injury, such as the extensive lacerations of the left hepatic lobe (dashed outline) depicted in c.

Vascular Injury

The pancreas is intimately associated with the central mesenteric vascular structures, and concomitant vascular injury may be seen with high-grade pancreatic trauma (Fig 14). Vascular injury may be uncontained (active bleeding) or contained (pseudoaneurysm and arteriovenous fistula) and usually manifests with indirect signs such as hemoperitoneum or focal hematoma. Arterial phase imaging is superior for identifying pseudoaneurysms (focal contained areas of contrast material pooling). Active bleeding is seen with the accumulation of an amorphous contrast material collection, with attenuation ranging from 85 to 370 HU. This active bleeding may be evident first during the arterial phase but increases in size and conspicuity during portal venous phase imaging (56). As previously discussed, although vascular injury is not included in the AAST-OIS classification, the radiologist needs to report it in a timely manner because it can affect the treatment and prognosis, regardless of the injury grade.

AAST-OIS grade V pancreatic injury with vascular complication in a                         32-year-old man after a motor vehicle collision that resulted in massive                         abdominal bruising and bilateral lower extremity fractures. Axial                         contrast-enhanced CT image shows an enlarged edematous pancreas, with loss                         of identifiable pancreatic architecture and poorly visualized pancreatic                         margins due to peripancreatic and retroperitoneal hemorrhage. A pooled focus                         of contrast material (arrow) with attenuation greater than that of the                         aorta, compatible with active contrast material extravasation, is depicted                         in the region of the pancreatic neck and head.

Figure 14. AAST-OIS grade V pancreatic injury with vascular complication in a 32-year-old man after a motor vehicle collision that resulted in massive abdominal bruising and bilateral lower extremity fractures. Axial contrast-enhanced CT image shows an enlarged edematous pancreas, with loss of identifiable pancreatic architecture and poorly visualized pancreatic margins due to peripancreatic and retroperitoneal hemorrhage. A pooled focus of contrast material (arrow) with attenuation greater than that of the aorta, compatible with active contrast material extravasation, is depicted in the region of the pancreatic neck and head.

Complications of Pancreatic Trauma

Although pancreatic trauma is relatively uncommon, complications are estimated to occur in 30%–50% of cases, with higher grades of injury associated with worse patient outcomes (1,38,42). The most common complications of pancreatic trauma include pancreatic fistula (20%–35% of cases), abscess (10%–18%), posttraumatic pancreatitis (10%), and pseudocyst (5%) (Fig 15) (1,11,38,57). Less common complications include vascular injury, MPD stricture resulting in chronic obstructive pancreatitis, septicemia, and multiorgan failure (42). In addition, because severe pancreatic trauma is often associated with multiorgan injury, it may be managed via an open abdomen. After longer periods of this management, the intra-abdominal contents may become encased by granulation tissue, leading to a “frozen abdomen” (5).

Peripancreatic fluid collection as a complication of pancreatic injury in                     a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c)                     and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete                     pancreatic parenchymal injury was identified at presentation; however, wispy                     high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the                     patient presented, an organized fluid collection (arrow in b) was visualized                     adjacent to the pancreatic tail and was treated with percutaneous drainage                     (arrow in c). (d) One year after the injury, the pancreas appears normal, and                     the fluid collection has resolved.

Figure 15a. Peripancreatic fluid collection as a complication of pancreatic injury in a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c) and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete pancreatic parenchymal injury was identified at presentation; however, wispy high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the patient presented, an organized fluid collection (arrow in b) was visualized adjacent to the pancreatic tail and was treated with percutaneous drainage (arrow in c). (d) One year after the injury, the pancreas appears normal, and the fluid collection has resolved.

Peripancreatic fluid collection as a complication of pancreatic injury in                     a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c)                     and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete                     pancreatic parenchymal injury was identified at presentation; however, wispy                     high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the                     patient presented, an organized fluid collection (arrow in b) was visualized                     adjacent to the pancreatic tail and was treated with percutaneous drainage                     (arrow in c). (d) One year after the injury, the pancreas appears normal, and                     the fluid collection has resolved.

Figure 15b. Peripancreatic fluid collection as a complication of pancreatic injury in a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c) and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete pancreatic parenchymal injury was identified at presentation; however, wispy high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the patient presented, an organized fluid collection (arrow in b) was visualized adjacent to the pancreatic tail and was treated with percutaneous drainage (arrow in c). (d) One year after the injury, the pancreas appears normal, and the fluid collection has resolved.

Peripancreatic fluid collection as a complication of pancreatic injury in                     a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c)                     and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete                     pancreatic parenchymal injury was identified at presentation; however, wispy                     high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the                     patient presented, an organized fluid collection (arrow in b) was visualized                     adjacent to the pancreatic tail and was treated with percutaneous drainage                     (arrow in c). (d) One year after the injury, the pancreas appears normal, and                     the fluid collection has resolved.

Figure 15c. Peripancreatic fluid collection as a complication of pancreatic injury in a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c) and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete pancreatic parenchymal injury was identified at presentation; however, wispy high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the patient presented, an organized fluid collection (arrow in b) was visualized adjacent to the pancreatic tail and was treated with percutaneous drainage (arrow in c). (d) One year after the injury, the pancreas appears normal, and the fluid collection has resolved.

Peripancreatic fluid collection as a complication of pancreatic injury in                     a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c)                     and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete                     pancreatic parenchymal injury was identified at presentation; however, wispy                     high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the                     patient presented, an organized fluid collection (arrow in b) was visualized                     adjacent to the pancreatic tail and was treated with percutaneous drainage                     (arrow in c). (d) One year after the injury, the pancreas appears normal, and                     the fluid collection has resolved.

Figure 15d. Peripancreatic fluid collection as a complication of pancreatic injury in a 34-year-old restrained passenger after a motor vehicle collision. Axial (a, c) and coronal (b, d) contrast-enhanced CT images were obtained. (a) No discrete pancreatic parenchymal injury was identified at presentation; however, wispy high-attenuation regions (arrow) reflect hemorrhage. (b, c) Seven days after the patient presented, an organized fluid collection (arrow in b) was visualized adjacent to the pancreatic tail and was treated with percutaneous drainage (arrow in c). (d) One year after the injury, the pancreas appears normal, and the fluid collection has resolved.

Missed or even misdiagnosed MPD injuries can lead to abscess and/or fistula formation (2). Patients with fistulas or pseudocysts should be diagnosed as having presumptive MPD injury, even if such an injury was not diagnosed at initial imaging (1,49,50). Unhealed MPD injury can lead to fistula formation between the injured pancreas and the adjacent organs and anatomic spaces (1). Although most fistulas heal with conservative management, they may require endoscopic stent placement or reconstructive surgery (38,57).

Abscess formation occurs secondary to inoculation from skin flora through a percutaneous surgical drain or secondary to communication with adjacent bowel (38). A complicated organized fluid collection seen at CT or MRI in the appropriate clinical setting suggests abscess formation. The presence of intracavitary gas increases confidence in a diagnosis of abscess. Posttraumatic pancreatitis is typically indistinguishable from nontraumatic pancreatitis and is characterized by organ edema, peripancreatic inflammatory stranding and fluid, and thickening of the left anterior renal fascia (11). An organized peripancreatic collection of simple fluid is consistent with pseudocyst and occurs more commonly after missed distal injuries or as a consequence of nonsurgical management (38).

MRCP to assess the integrity of the MPD is helpful for guiding the management of posttraumatic pseudocyst, because an intact MPD is usually responsive to percutaneous drainage, whereas a disrupted MPD requires endoscopic stent placement (38,58). Erosions caused by free pancreatic enzymes can result in arterial pseudoaneurysm, most often involving the splenic, gastroduodenal, or common hepatic arteries, and visceral venous thrombosis (38). Visceral artery pseudoaneurysms are life threatening owing to the potential for rupture and subsequent exsanguination. Posttraumatic fibrosis of the MPD can lead to ductal structuring and subsequent chronic obstructive pancreatitis, which can manifest months to years after the traumatic injury (11,59).

Management of Pancreatic Trauma

Teaching Point Management of traumatic pancreatic injuries depends on multiple factors, including mechanism of injury (blunt versus penetrating trauma), AAST-OIS injury grade, hemodynamic status of the patient, and extent of associated organ damage (Fig 16).
Although several management pathways and decision-making tools have been proposed, there is limited evidence on which to base decisions.

Management algorithm for pancreatic trauma. Low-grade (grades I and II)                     pancreatic injuries are typically managed nonsurgically, whereas high-grade                     (grades III–V) injuries may require resection with possible                     reconstruction and/or drainage procedures.

Figure 16. Management algorithm for pancreatic trauma. Low-grade (grades I and II) pancreatic injuries are typically managed nonsurgically, whereas high-grade (grades III–V) injuries may require resection with possible reconstruction and/or drainage procedures.

In the setting of abdominal trauma, the initial management is based on the patient’s stability, with priority given to controlling bleeding and intestinal content spillage. Unstable patients are often managed immediately with exploratory laparotomy and damage-control surgery. Peripancreatic fluid collections can be managed with closed-suction drainage systems (57,60).

Once the patient is stabilized, subsequent management of the pancreatic injury can be planned on the basis of patient factors and extent of pancreatic and associated organ damage. Patients with low-grade (grades I and II) pancreatic injuries are typically managed nonsurgically, as these injuries do not involve the MPD (61). Management options include supportive care (fluid resuscitation, analgesia, and close monitoring of vital signs and laboratory values), surgical hemostasis, and/or closed-suction drainage (57,60,62). Even with similar treatments, a grade II injury is associated with higher mortality and is sometimes treated surgically, such as in cases of hemodynamic instability (63).

Once there is involvement of the MPD (ie, high-grade [grades III–V] injury), there is increased risk of complications such as abscess or fistula formation, and more aggressive treatment such as ERCP or surgery is usually recommended (64). Stable patients with evidence of pancreatic transection or extensive peripancreatic fluid may require management with exploratory laparotomy (60). Grade III and grade IV pancreatic injuries are commonly managed surgically to prevent pancreatic ascites or a major fistula (60). Proximal MPD injuries (to the right of the SMV–portal vein axis) can be managed with closed-suction drainage, with or without endoscopically guided stent placement. Distal MPD injuries (to the left of the SMV–portal vein axis) are often treated with distal pancreatectomy.

Pancreatic head injuries pose particular challenges for the surgeon, given the technical difficulty and potential complications associated with pancreatic head resection in the acute setting. It has been proposed that the safest option, and one that can be easily accomplished by the majority of surgeons, is to manage these injuries with external drainage, provided there is no devitalized tissue and the ampulla is intact (15,54). Definitive management with pancreaticoduodenostomy or pancreaticojejunostomy can be performed once the patient is stabilized.

Grade V pancreatic injuries typically lead to damage-control surgery with drainage. Because duodenal injuries often coexist with this grade of injury, gastric diversion is accomplished with pancreaticojejunostomy or pancreaticogastrostomy, with the latter more preferred (60). Although pancreaticoduodenectomy in the setting of grade V pancreatic injury is controversial, it is still performed at some institutions (62).

Conclusion

Blunt traumatic pancreatic injuries can be easily overlooked, given the low frequency of occurrence, subtle imaging findings, and associated multiorgan trauma. Multiphasic contrast-enhanced CT is the initial imaging modality of choice for suspected pancreatic trauma. The type and location (proximal versus distal) of injury are used to assign an AAST-OIS grade. CT can lead to underestimation of the degree of pancreatic injury, particularly in the early period after the trauma, and has limitations in the assessment of the MPD.

The integrity of the MPD is the major determinant of patient outcome, predicting morbidity and mortality. MRI/MRCP facilitates noninvasive assessment of MPD integrity. Although not included in the AAST-OIS classification, vascular injury, such as active contrast material extravasation, is important for determining patient management and predicting outcomes and must be reported in a timely manner. Management of traumatic pancreatic injuries depends not only on the injury mechanism and AAST-OIS grade but also on the hemodynamic status of the patient and the extent of other organ damage. Low-grade pancreatic injuries (grades I and II) are typically managed nonsurgically, whereas high-grade injuries (grades III–V) may require resection with possible reconstruction and/or drainage procedures.

Disclosures of Conflicts of Interest.—J.T.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: grant (paid to principle investigator, not J.T.L.) from the American Society of Emergency Radiology. Other activities: disclosed no relevant relationships. C.H. Activities related to the present article: Crash Injury Research grant from the National Highway Traffic Safety Administration. Activities not related to the present article: disclosed no relevant relationships. Other activities: disclosed no relevant relationships. T.N.H. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: grant (paid to principle investigator, not T.N.H.) from the American Society of Emergency Radiology. Other activities: disclosed no relevant relationships.

Acknowledgment

The authors thank Tom Dolan for his technical assistance in preparing the illustrations for this article.

Recipient of a Certificate of Merit award and Magna Cum Laude award for an education exhibit at the 2019 RSNA Annual Meeting.

For this journal-based SA-CME activity, the authors J.T.L, C.H., and T.N.H. have provided disclosures; all other authors, the editor, and the reviewers have disclosed no relevant relationships.

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Article History

Received: Apr 25 2020
Revision requested: June 25 2020
Revision received: July 21 2020
Accepted: Aug 4 2020
Published online: Nov 27 2020
Published in print: Jan 2021