case study nhung 11.12.12

Imaging Report

LE HONG NHUNGPaediatric RadiologistNational Hospital of PeadiatricsHa Noi

Bui Thanh Nam, Boy 10Y , SICU

DOA: December 10th, 2012

Dx: Abdominal trauma

Clinical History: the previous 2 week, traffic accidents:the direct impact on the upper abdomen of the wheel or the handlebars. 2-7 days later feel abdominal pain, vomit => local Hospital (Ninh Binh): pancrea trauma=> NHP

EFILM

Diagnosis and Classification of Pancreatic and Duodenal Injuries

Introduction Mechanism Clinical Feature Laboratory Findings CT protocol Classification

Introduction

P andD trauma is uncommon, < 2% of all abdominal injury isolated injuries (<30%). Coexisting injuries (50%–98%) Mortality for P injuries ranges from 9% to 34%; for D injuries it

ranges from 6% to 29% predictors of outcome: the mechanism of injury, the time to

diagnosis, and duodenal perforation, Complication after 48h of survivors: pancreatitis, pseudocysts,

fistulas, intraabdominal abscesses, pneumonia, development of multiorgan failure and septicemia

When a definitive diagnosis is delayed for more than 24 hours, up to 40% of patients are at risk of death, as opposed to 11% of those patients operated on within 24 hours.

Mechanism of Injury

Result from severe AP compression trauma against the spinal column: seat belt, wheel, handlebar compression trauma.

Blunt P trauma more common among children: less protection by thinner layer of peripancreatic fat.

Force on R quadrant: head P, D2 and others (liver, bile duct, GB, ascending colon, R kidney)

Force on L quandrant:SMA, Body P, tail, D4 and others (spleen, stomach, L Kidney)

Clinical and Subclinical Feature

comprise a triad of leukocytosis, raised serum amylase activity, which can be absent in the first few days.

upper abdominal pain.

Laboratory Findings

serum amylase activity be raised, although remains normal for 2–48 hours after an injury.

Repeated testing is recommended, for follow-up studies and to monitor pancreatic injury

Serum lipase activity is also not specific for pancreatic injury.

Trypsinogen-activating peptide has not been fully evaluated so far.

Imaging Protocols

MD CT reduces motion artifacts and enables high-resolution scans,

thickness scanning of 2.5–5.0 mm 2 mL/kg of body weight of contrast medium injected at 3–6

mL/sec with a delay of 60–70 seconds in the portal venous (60–70-second) phase.

Arterial scans (25–30-second delay) in a whole-body CT protocol or a dedicated pancreatic CT protocol (35–40-second delay)

Delayed scanning (at 2–3 minutes) in cases of suspected active abdominal (including pancreatic) hemorrhage.

The use of oral contrast media remains controversial, applied to duodenum suspected to distend the duodenal wall, not likely to used for Emergency diagnosis.

CT finding Duodenal Injury

Duodenal perforation is suspected if retroperitoneal collection of contrast medium, extraluminal gas, or a lack of continuity of the duodenal wall.

Duodenal contusion is suspected with edema or hematoma of the duodenal wall, intramural gas accumulations, and focal duodenal wall thickening (>4 mm).

Fluid or a hematoma in the retroperitoneum,

Duodenal Classification (AAST)

CT finding pancreatic injury

Normal limits in the first 12 hours after the injury; The sensitivity and specificity of CT around 80%-

91%(MDCT) Specific signs on CT: lacerations of the pancreas,

edema or hematoma of the pancreatic parenchyma, active hemorrhage from the pancreas, and blood collections between the parenchyma and the splenic vein 1%

Pancrea injury classification (AAST)

ERCP and MRI

ERCP can demonstrate extravasation of contrast medium from the pancreatic duct.

If the injury of the pancreatic duct is not clear, MR imaging is used in combination with MRCP and ERCP

LOOK AT OUR CASE !

Edema reduce the correct imaging diagnosis: present 14 days.

Active bleeding may from SMV. At admission: Grade 2-3 for DI, and Grade 2-

3 for PI (not certify ductal injury).

MANAGEMENT

- injury without ductal injury: Drainage - injury with ductal injury which can be either

proximal or distal relative to the superior mesenteric vessels:

- Isolated injury :suction drainage and hence the formation of a controlled fistula,

- Coexisting injury with massive destruction of P, D may force pancreatoduodenectomy

TAKE HOME POINT

P and D injuries is challenging and requires close attention to the choice of technique and the subtle signs of injury (Normal limits in the first 12 hours after the injury), LAB test normal 2-48h.

Repeated CT and LAB test should be considered when there is a strong suspicion of pancreatic injury despite normal findings at admission

When delayed diagnosis for more than 24 hours, up to 40% of patients are at risk of death

Grade 1-DI

Figure 1.  Grade I duodenal injury. Axial CT image shows thickening of the duodenal wall (arrow) in the descending part without evidence of free air. There is stranding of the peripancreatic fat.

Grade 2- DI

Figure 2a.  Grade II duodenal injury. (a) Axial CT image shows an enlarged pancreatic head with mild edema (arrow) (grade I lesion). (b) CT image obtained at a lower level shows thickening of the duodenal wall in the descending part (black arrow). Adjacent to the duodenum is a small collection of extraluminal air (white arrow), which indicates a small grade II laceration of the wall.

Grade 2 - DI

Figure 3.  Grade II duodenal injury. Axial CT image shows a grade II injury of the horizontal part of the duodenum with small collections of extraluminal air (arrows). A subcapsular hematoma is present at the lower pole of the right liver lobe

(arrowhead).

Grade 3-DI

Grade III duodenal injury. Axial CT image shows thickening of the duodenal wall and disruption of the wall (white arrow).

Grade 1- PI

. Axial CT image shows a minor contusion of the pancreatic body (black arrow)

Hematoma (white arrow)

Grade 2-PI

The pancreatic tail is slightly displaced anteriorly because of a peripancreatic hematoma. Both adrenal glands are thickened (black arrows), a finding suggestive of contusion

Grade 3-PI

Axial CT image shows diffuse edema of the pancreatic parenchyma with some defined areas of contusion (black arrow). There is a transection across the pancreatic body (white arrow).

Grade IV-PI

Axial CT image shows a proximal pancreatic transection (black arrow) with a large peripancreatic hematoma. There is also active bleeding (white arrow)

THANK YOU FOR YOUR ATTENTION!