Trauma pancreas

                         A note on definition: surgeons define distal pancreas as that part containing the tail of the pancreas, while proximal means pancreatic head. Other abdominal injuries are common in patients with pancreatic trauma. The exception is with bicycle handlebar injuries, which are a common cause of mechanical pancreatic trauma in children; these tend to produce isolated pancreatic injury and often lead to pseudocysts.
                         Both clinical and radiologic diagnosis of pancreatic injury is fraught with difficulty. Even in a setting of major pancreatic injury, at times initial physical findings are mild or masked by other trauma. Both CT and ERCP are often necessary to diagnose pancreatic fracture and duct disruption. The most common site for fracture is at the pancreatic head and neck junction.
This is radiology images of Traumatic pancreatic rupture (arrow) in a 7 yearold boy.

                    In many institutions CT is the imaging modality of choice in suspected pancreatic trauma. In both adults and children CT findings of pancreatic trauma can be subtle. At times an adjacent hematoma is the only suggestion of pancreatic injury. A pancreatic laceration, including complete transection, may not be apparent initially with CT. Therefore, with a strong suspicion for pancreatic injury and an unremarkable initial CT, a follow-up study 12 to 24 hours later is often helpful.
                    A CT finding of fluid (peripancreatic blood) separating the splenic artery or vein from pancreas suggests pancreatic injury. Still, such fluid may also be present in the absence of any pancreatic injury, and thus additional CT findings should be sought. In general, CT cannot directly detect pancreatic duct injury, although a deep pancreatic laceration suggests duct disruption. Endoscopic
retrograde cholangiopancreatography is the primary study in evaluating pancreatic duct injury. Nevertheless, to better delineate pancreatic duct injury, one group of Japanese investigators performed repeat CT shortly after completing ERCP, believing that such an approach confirms ERCP findings, detects injuries not identified on ERCP, and excludes injuries in patients with equivocal ERCP. Magnetic resonance pancreatography can detect complete main pancreatic duct disruption,
although the literature on this topic is sparse. Current MRCP application is primarily in defining pancreatic ducts not evaluated with ERCP. 
                      Management of children admitted with a diagnosis of pancreatic injury is individualized, keeping in mind that, in the absence of clinical deterioration or major duct injury, a more conservative therapeutic approach has evolved than practiced previously. In children with pancreatic injury a primary consideration of whether to operate or not often depends on the status of the pancreatic duct. Yet even with duct injury the trend is toward more conservative therapy. Anecdotal reports suggest that some transected pancreatic ducts recanalize spontaneously.
                        Duct disruption in some patients, at times involving a secondary or smaller duct, leads to pseudocyst formation. Classic therapy for traumatic pancreatic pseudocysts is cystogastrostomy or distal pancreatectomy. Children with pancreatic duct disruption and pseudocysts, however, have had successful long-term cyst catheter drainage.
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