Pancreatic trauma

Introduction to pancreatic trauma The pancreas is a gland with internal and exocrine functions. It has a deep position and is protected by the spine after the rib cage. Therefore, there are fewer chances of injury, so it is often misdiagnosed. It was not until 1952 that there was a comprehensive report on pancreatic injury. Pancreatic damage accounted for 0.4/100,000 of the population and 0.2 to 0.6% of abdominal trauma. Pancreatic injuries in wartime are mostly penetrating injuries, often due to the high mortality rate associated with major bleeding. On average, it is caused by a severe closed injury in the abdomen. Sometimes the accidental injury to the surgery, the ratio of pancreatic penetrating injury to closed injury is about 3:1. In a group of 1984 cases of pancreatic trauma, penetrating injuries accounted for 73%, and closed injuries accounted for 27%. basic knowledge The proportion of the disease: the incidence of this disease in patients with abdominal trauma is about 0.01% - 0.02% Susceptible people: no special people Mode of infection: non-infectious Complications: pancreatic abscess pancreatic fistula

Cause of pancreatic trauma

Traffic accident (35%):

In traffic accidents, especially when the car driver is driving at a high speed, the car suddenly hits the object, and its strong inertia causes the driver's upper abdomen to hit the steering wheel of the car, causing pancreatic injury, sometimes when the human body falls from a height. The waist is overly curved, and the bilateral rib arches are extremely adducted. In an instant, a burst of force is squeezed on the pancreas, causing different degrees of damage to the pancreas.

Violence factor (25%):

The location of the pancreatic injury varies with the direction of the external force. The pancreas head is common in the body. When an external force acts on the right upper abdomen or the right side of the spine, the pancreatic head is easily squeezed, and the duodenum is often combined. Biliary tract, liver damage, such damage is serious, the mortality rate is very high up to 70 ~ 80%; when the external force directly acts on the middle of the upper abdomen, the damage is mostly the neck of the pancreas, part or complete fracture of the body, combined with mesentery Upper arterial injury; external force acts on the left side of the spine, and the tail of the pancreas is often vulnerable to injury.

The pathological changes of pancreatic closure injury are progressive. Surgeons often focus on the treatment of pancreatic fractures, and they often pay attention to the local contusion of the pancreas. This is mainly due to the characteristics of its pathological changes. Not enough knowledge.

Pancreatic trauma prevention

Since the disease is caused by trauma, there are currently no preventive measures. In life, we must work and rest, live in order, and maintain an optimistic, positive, and upward attitude towards life.

Pancreatic trauma complications Complications pancreatic abscess pancreatic fistula

After pancreatic injury, although the treatment is more reasonable, the mortality rate is still high, and the death caused by the damage of the accompanying large blood vessels or surrounding organs often exceeds the death caused by the pancreatic injury itself. Among the survivors More than 30% of complications occur: such as major bleeding, pancreatic abscess, pseudo-pancreatic cyst, pancreatic fistula and so on.

1. Major bleeding: It is one of the most dangerous complications after pancreatic injury, and it often dies due to difficulty in treatment.

2. Pancreatic abscess: less common, often secondary to the more severe pancreatic contusion, contusion of contused pancreatic tissue, further formation of abscess.

3. Pancreatic fistula: is the most common complication of pancreatic trauma, can be as high as 20 to 40%, with the highest incidence of pancreatic head contusion.

Symptoms of Pancreatic Trauma Common Symptoms Pancreatic Abdominal Pain Abdominal Hemorrhage Blood Loss Tissue Necrosis Immunity Decline Vascular Injury Open Injury Small Intestinal Injury Shock

1. Only the pancreas itself is damaged, and it often does not cause immediate death in the early stage. Early deaths are often caused by mergers with other parenchymal injuries, or large blood vessel damage.

2. In the case of simple pancreatic injury or mild combined injury, there are often no obvious symptoms and specific signs in the early stage. The delay in treatment increases the incidence of comorbidities.

3. Necrosis and hemorrhage around the tissue, the digestion of pancreatic enzyme causes necrosis and hemorrhage of surrounding tissues, and the complication after injury is as high as 30-50%.

4. Multiple organ failure, due to tissue necrosis and pollution, blood loss, shock, decreased immunity, infection is often prone to multiple organ failure, and the mortality rate is very high.

5. In the early stage of moderate injury, and the secretion of pancreatic juice is temporarily inhibited after injury, or the release of pancreatic enzyme has not been activated, the early symptoms are not typical.

6. The incidence of pancreatic injury combined with other organ injury is very high, open injury combined with other organ injuries: liver injury, gastrointestinal injury, duodenal injury, spleen injury, kidney injury, small intestine injury, colon injury, blood vessel Injury and so on. Closed pancreatic injury combined with other organ injuries: liver injury, gastric injury, duodenal injury, spleen injury, small intestinal injury, vascular injury, etc.

Pancreatic trauma examination

1. Laboratory tests: serum phospholipase A2 (SPLA2), C-reactive protein, 1-antitrypsin, 2-macroglobulin polycytosine ribonucleic acid (poly-(c)-specifi RNAase), serum methemoglobin , plasma fibrinogen, etc., these items have a good reference value, but not yet widely used.

2. B-mode ultrasound and CT examination: small omental effusion, pancreatic edema, etc., pathological changes due to pancreatic injury are progressive, therefore, imaging examination should also be done dynamically, but sometimes confused with retroperitoneal hematoma .

3. Abdominal lavage or abdominal puncture: In the early stage of pancreatic injury, there may be few fluids in the abdominal cavity, and the puncture is often negative. Therefore, in addition to mastering the time of abdominal puncture, multiple punctures can achieve a definite diagnosis.

Diagnosis and diagnosis of pancreatic trauma

diagnosis:

Combined with the medical history, the diagnosis can be confirmed without identification.

1. Do not ignore the upper abdominal contusion

Where the blunt contusion of the upper abdomen, regardless of where the force comes from, should consider the possibility of pancreatic injury, when the pancreas is broken with large vascular injury, there are more obvious abdominal signs, and the pancreatic damage range is small, and in the hidden part It is easy to ignore in the early days and can be found in a few days or even weeks.

2. To correctly judge serum amylase

Sometimes it is mistaken that amylase must be elevated after pancreatic injury, neglecting the time of amylase elevation, and the serious pancreatic injury amylase may not rise, thus delaying diagnosis. After pancreatic injury, serum phosphatase is mostly elevated (about 90%), but the damage is proportional to the time of elevation. In 179 cases of pancreatic blunt contusion, serum amylase increased only 36 cases (20%) within 30 minutes after injury. Therefore, pancreatic enzyme secretion is temporarily suppressed in the early stage of pancreatic injury, so it may not be elevated. Repeated measurements should be made to make dynamic observations. The presence of pancreatic damage must not be denied because the serum amylase is not high after the injury. It has been suggested that when pancreatic injury is suspected, the amount of amylase collected in the urine for 2 hours is more reliable than the determination of serum amylase. It is also feasible to perform abdominal biopsy or lavage for amylase assay to aid diagnosis. In the peritoneal body fluid after pancreatic injury, amylase is rapidly increased, and most of them are positive.

3. Have a full understanding of the development of the course of the pancreas after injury

Pancreatic injury is a contusion, severe cases can be broken, ruptured, sometimes combined with duodenal injury. When the symptoms of pancreatic contusion begin to conceal and when the pancreatic juice oozes to a certain extent, self-digestion presents obvious symptoms. In severe contusion and the pancreatic capsule is not broken, due to the swelling of the tissue of the contusion, the "tightening" effect of the pancreatic capsule, the damage of the pancreatic tissue is often progressive and even necrotic.

4. Pancreatic injuries are often confused with other organ injuries

Because the surrounding of the pancreas is adjacent to large blood vessels and organs, it is often confused with other organ injuries, which makes the diagnosis difficult. Sometimes only the large vascular injury or other substantial organ injury is considered, and the pancreatic injury is missed.

5. Other inspections

B-mode ultrasound and CT examination: have a certain diagnostic value for pancreatic injury, and the positive rate is higher.

Fiberoptic duodenoscopy retrograde cholangiopancreatography (ERCP): The positive rate of diagnosis of pancreatic injury is very high, especially to determine the presence or absence of pancreatic duct injury.

Peritoneal lavage or abdominal puncture: The diagnostic value of this method is large, and the positive rate is almost 100% (the amylase is increased in the peritoneal blood extract).

6. Intraoperative diagnosis points

Severe pancreatic contusion or rupture, a clear diagnosis can be made after laparotomy: intra-abdominal hemorrhage and retroperitoneal hematoma, hemorrhage in the small omental sac, etc., generally no difficulty in diagnosis. Those with minor injuries are prone to omission. Therefore, when suspected of pancreatic injury, a thorough examination must be performed.

The incision for laparotomy should be large enough. Lift the transverse colon and push the small intestine down, touching the base of the mesentery, the lower edge of the pancreas and adjacent tissues. Cut the stomach ligament, lift the stomach up, and pull the colon downward. The posterior peritoneum of the outside of the duodenum was dissected and the duodenum was freed to explore the dorsal side of the head of the pancreas and to determine whether there was a duodenal injury. The posterior peritoneum of the upper and lower margins of the pancreas was incised and the back of the pancreas was removed as needed. During the exploration, patients with hematoma on the pancreas should be examined and cut open. Even small hematomas cannot be ignored. The damaged pancreatic tissue is under the hematoma. It has been emphasized that the possibility of pancreatic injury should be considered in all cases of retroperitoneal retroperitoneal hematoma. In the cases we treated, there was almost a hematoma in the posterior peritoneum. Mild pancreatic injury, the capsule is usually intact, only local edema, ecchymosis around the pancreas and varying degrees of bleeding.

In order to confirm the presence or absence of rupture of the pancreatic duct, it was advocated to remove a small portion of retrograde intubation angiography of the pancreatic tail. The duodenum can also be incision and cannulated through the duodenal papilla. This method of examination is only used for severe pancreatic contusion, a wide range, and it is difficult to confirm whether the pancreatic duct is broken. If it is a simple contusion, it can only be cured by adequate drainage. If the pancreatic tail is removed or the duodenal intubation is performed, it will aggravate the trauma and cause pancreatic fistula or duodenal fistula, which increases the treatment. difficult. To this end, the methylene blue injection method can be used: when 1 ml of methylene blue is added to 4 ml of water (saline) and injected into the distal normal pancreatic tissue, the methylene blue can overflow through the damaged main pancreatic duct.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.