1. SOLID ORGAN INJURIES
FOLLOWING ABDOMINAL
TRAUMA
MODERATORS – PROF DR R.K. DEKA
PROF DR H.K. BHATTACHARYYA
PROF DR A. AHMED
PRESENTED BY- DR AYMEN AHMAD KHAN
PGT SURGERY

2. INTRODUCTION
Motor vehicle accidents are responsible for 75% of
all blunt trauma abdominal injuries
More common in elderly due to less resilience.
Blunt injuries causes solid organ trauma (spleen,
liver and kidneys) more often than hollow viscera.
Multi organ injury and multiple system injury are
also more common in blunt injury than in other
types.
Spleen is most common intra abdominal organ to be
injured followed by liver.

3. ORGAN INJURIES
SOLID ORGANS-
• Solid organs most commonly injured in blunt traumas
• In decreasing incidence of injury
• Spleen, liver, kidneys, intraperitoneal small bowel, bladder,
colon, diaphragm, pancreas and duodenum
HOLLOWVISCERA:
- duodenum commonly injured
- Small bowel injured at relatively fixed areas (duodenojejunal
flexure and ileocaecal junction) by shearing force
- Colon relatively protected.
- Gaseous distension of caecum – most vulnerable part as
fixed.
- Stomach rarely injured – compression cause esophagogastric
junction bursting

4. RETROPERITONEUM AND UROGENITALTRACT
• Kidney injury - common next to spleen and liver
• Pancreatic injury - 4% cases of trauma
• Bladder - most commonly injured extra peritoneally by shearing at the
vesico urethral junction.
- intraperitoneally by blunt force on distended bladder
• Rupture of prostatic urethra by shear forces is commonly seen with
haemorrhage
CHILDHOODTRAUMA
• Blunt trauma secondary to MVAs, falls or child abuse is primarily
responsible for 90% of childhood injuries.
• Predominance - Solid organ abdominal injuries.
• Non-op. management – 90% success rate (standard of care in solid
organ injuries)
• Overall mortality – approx 15% or < (if major vascular injuries
excluded)
• Mortality from severe blunt trauma abdomen is higher than
penetrating injuries

5. MECHANISM OF INJURY
• Direct application of a blunt force to the
abdomenCRUSHING
• Sudden decelerations apply a shearing force
across organs with fixed attachments
SHEARING
• Raised intraluminal pressure by abdominal
compression accurately in hollow organs can
lead to rupture
BURSTING
• Disruption of bony areas by blunt trauma may
generate bony spicules that can cause
secondary penetrating injury
PENETRATION

6. BLUNT ABDOMINALTRAUMA
• Direct impact or movement of
organs
• Compressive, stretching or
shearing forces
• Solid Organs > Blood Loss
• Hollow Organs > Blood Loss and
Peritoneal Contamination
• Retroperitoneal > Often
asymptomatic initially

7. PRESENTATION
• Varies widely from haemodynamic stability with
minimal abdominal signs to complete
cardiovascular collapse and may change from one
to the other with alarming rapidity

8. INITIAL ASSESSMENT
Whether the
patient is
haemodynamically
-stable
-unstable
FIRST PRIORITIES
PROTOCOL :
• Brief clinical
examination to
evaluate ABC along
with cardiovascular
status with blood
pressure and pulse
measurement
Accordingly,
resuscitation and
management of
shock by
• maintenance of ABC
• IV fluids
• nasogastric tube insertion
• Catheterization

9. SECOND PRIORITIES PROTOCOL
Physical examination
Base line investigations
Four quadrant tap
Diagnostic peritoneal lavage (DPL)
Ultrasound – FAST (focus assessment with sonography for trauma)
Abdominal CT scan
Diagnostic laparoscopy
Laparotomy

10. PHYSICAL EXAMINATION
General Examination : relating to hemodynamic stability
Abdominal findings:
Inspection :
• for abdominal distension
• for contusions or abrasions
• lap belt ecchymosis – mesenteric, bowel, and lumbar spine injuries
• periumblical (Cullen sign) and flank (GreyTurner Sign) ecchymosis –
retroperitoneal haematoma

11. Palpation :
• for tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum
Percussion :
• Dullness/ shifting dullness – intrabdominal collection
Auscultation :
• bowel sounds present/absent.
Rectal findings
Check for gross blood - pelvic fracture
Determine prostate position – high riding prostate – urethral injury
Assess sphincter tone – neurologic status

12. DIAGNOSTIC STRATEGY
to identify
those with
injuries
to decide
which ones
need
laparotomy
how quickly
this must be
undertaken

13. BASIC INVESTIGATIONS
• Complete haemogram with hematocrit,
ABG, Electrocardiogram
• Renal function tests
• Urine analysis –
• +nce of hematuria – genito urinary injury
• -nce of hematuria – does not rule out it
• Serum amylase / lipase or liver enzymes -
se -suspicion of intraabdominal injuries

14. • Chest radiograph –
• Pneumothorax/hemothorax
• Raised left/right hemidiaphragm –
perisplenic/hepatic hematoma.
• Lower ribs fracture – liver/spleen injury.
• Abdominal contents in the chest –
• ruptured hemidiaphragm
• Abdominal radiographs –
- Pneumoperitoneum –perforation of hollow viscus
- Ground glass appearance –massive hemoperitoneum

15. - Dilated gut loops- retroperitoneal hematoma or injury
- Retroperitoneal air outlining the right kidney –
duodenal injury
- Double wall sign – air inside and outside the bowel
- Distortion or enlargement of outlines of viscera –
hematoma in relation to respective organs
- Medial displacement of stomach – splenic hematoma
- Obliteration of Psoas shadow – retroperitoneal
bleeding
- Pelvic bone fracture – bladder/urethral/rectal injury
- Fracture vertebra – ureter injury / retroperitoneal
hematoma

16. INDICATIONS FOR FURTHERTESTING
Unexplained haemorrhagic shock
Major chest or pelvic injuries
Abdominal tenderness
Diminished pain response due to -
• Intoxication
• Depressed level of consciousness
• Distracting pain
• Paralysis
Inability to perform serial examination

17. FOUR
QUADRANT
TAP:
Overall accuracy
– about 90%
Positive tap –
obtaining 0.1 ml
or more of non
clotting blood
Negative tap
does not rule
out
haemorrhage
DIAGNOSTIC
PERITONEAL
LAVAGE
Criteria for positive
tap –
Gross bloody tap
>1,00,000 RBCs per
mm
> 500 white blood cells
per mm
Elevated amylase level
Presence of bile or
bacteria or faeces

18. ULTRASOUND
FAST EXAMINATIONS (focused assessment
with sonography for trauma).
ADVANTAGES
Inexpensive,
noninvasive and
portable
Performed by
emergency
physicians and
surgeons trained in
performing FAST
examinations.
Avoids risks associated
with contrast media
Confirms presence of
hemoperitoneum in
minutes
•Deceases time to laparotomy
•Great adjunct during multiple
casualty disasters
Serial examination
can detect ongoing
hemorrhage
Differentiates
pulseless electrical
activity from extreme
hypotension

19. DISADVANTAGES
A minimum of 70 ml
of intraperitoneal
fluid for positive
study.
Accuracy is
dependent on
operator /
interpreter skill and
is decreased with
prior abdominal
surgery.
Technically difficult
with – obese, ileus or
subcutaenous
emphysema is present
Does not define exact
cause of
hemoperitoneum
Sensitivity is low for
small-bowel and
pancreatic injury
Sensitivity – 69%-
99%

20. Technique -
Four basic transducer positions used
to find abdominal fluid.

21. ABDOMINAL CT SCAN
-Latest generation of
helical and multislice
scanners provides rapid
and accurate
diagnostic information.
-Criterion standard for
solid organ injuries.
-Help quantitate the
amount of blood in the
abdomen and can
reveal individual
organs with precision

23. Diagnostic Modalities in AbdominalTrauma

24. * Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in blunt
abdominal trauma. JTrauma 29:242, 1999.
** Meyer D M,Thal E R,Weigelt J A, et al:The role of abdominal CT in the evaluation of
stab wounds to the back. JTrauma 29:1226, 1999.

25. LAPAROSCOPY
ADVANTAGES
extent of organ injuries and determines
the need for laparotomy
Defines which intraabdominal injuries
may be safely managed nonsurgically
More sensitive than DPL or CT in
uncovering -
• Diaphragmatic injuries
• Hollow viscus injuries
Surgery can be done in same sitting
• With laparoscope with minimal trauma
• Open surgery
DISADVANTAGES:
pneumoperitoneum may
elevate ICP
General anesthesia
usually necessary
Patient must be
hemodynamically stable

26. LAPAROTOMY
Peritonitis (gross blood, bile
or faeces)
Pneumoperitoneum or
pneumoretroperitoneum
Evidence of diaphragmatic
defect
Gross blood from stomach
or rectum
Abdominal distension with
hypotension
Positive diagnostic test for
an injury requiring operative
repair
INDICATIONS

28. SPLENIC INJURY
The spleen is the intra-abdominal organ most
frequently injured in blunt trauma
Spleen lies in posterior portion of lt upper quadrant,
deep to ninth ,tenth and eleven ribs
Convex surface lies under lt hemidiaphargm
Concavities on medial side due to impression by
neighbouring structures
Average length 7-11cm
Weight 150 grams (70-250)
Tail of pancreas lies incontact with spleen in 30% and
within 1cm in 70%

29. Arterial Supply andVenous drainage
Splenic artery provides major blood supply
Arises from coeliac artery (ocassionaly aorta or
SMA)
Tortrous course (average 13 cm)
Small blood supply from short gastric vessels.
Venous drainage is through splenic vein
Joins superior mesenteric vein to form portal vein

31. SUSPENSORY LIGAMENTS
Provide attachment
of spleen with
adjacent structures
These ligaments are
avascular except
gastrosplenic
ligament (containing
short gastric and
gastroepiploic artery)
GASTROSPLENIC SPLENORENAL
SPLENOPHRENIC SPLENORENAL

32. PRESENTATION
Patient may
present with the
upper abdominal or
flank pain
Referred
pain to the
shoulder
(kehr sign)
Some may be
asymptomatic
Physical examination
is insensitive and non
specific.
Pt may have signs
of lt upper quadrant
tenderness or signs
of generalized
peritoneal irritation.
May present with
tachycardia
,Tachypnea, anxiety ,
Hypotension (shock)

33. Organ Injury Scaling-American
Association of the Surgery ofTrauma
(OIS-AAST)

34. MANAGEMENT
Nonoperative management of
splenic injury is successful in >90%
of children, irrespective of the
grade of splenic injury.
Non operative management
successful in adults 65%
unstable patients suspected of
splenic injury and intra-abdominal
hemorrhage should undergo
exploratory laparotomy and splenic
repair or removal.
blunt trauma patient with evidence
of hemodynamic instability
unresponsive to fluid challenge with
no other signs of external
hemorrhage should be considered
to have a life-threatening solid
organ (splenic) injury until proven
otherwise.

35. FLOWCHART FOR MANAGEMENT

36. Criteria for
non
operative
management
Haemodynamic
stability
Negative
abdominal
scan
Absence of
contrast
extravasation on
CT
Absence of other
clear indications
for exploratory
laprotomy
Absence of conditions
associated with
increased risk of
bleeding
(Coagulopathy, use of
anticoagulants,
cardiac failure, )
Failure rate for non operative(Adults)
GRADE 1 - 5% GRADE 2 - 10%
GRADE 3 - 20% GRADE 4 - 33%
GRADE 5 - 75%

37. SURGERY
• operative therapy of choice is splenic conservation where possible
to avoid the risk of death from opportunistic postsplenectomy
sepsis that can occur after splenectomy for trauma. However, in
the presence of multiple injuries or critical instability, splenectomy
is more rapid and judicious.
SPLENECTOMY
• Exploration is through a long midline incision.The abdomen is
packed and explored. Exsanguinating hemorrhage and
gastrointestinal soilage are controlled first
• splenic ligamentous attachments are taken down sharply or
bluntly to allow for rotation of the spleen and the vasculature to
the center of the abdominal wound and to identify the splenic
artery and vein for ligation.

38. • Once the splenic artery and vein are identified and controlled by
ligation,
• The gastrosplenic ligament with the short gastric vessels is divided
and ligated near the spleen to avoid injury or late necrosis of the
gastric wall.
• Drains are typically unnecessary unless concern exists over injury to
the tail of the pancreas during operation.

39. SPLENORRAHPHY
• Parenchyma saving operation of spleen
• The technique is dictated by the magnitude of the splenic
injury
• Nonbleeding grade I splenic injury may require no further
treatment.Topical hemostatic agents, an argon beam
coagulator, or electrocautery
• In grade 2 and 3 suture repair (horizontal mattress) , or mesh
wrap of capsular defects. Suture repair in adults often
requiresTeflon pledgets to avoid tearing of the splenic
capsule

41. PARTIAL SPLENECTOMY
• Grade IV toV splenic injury may require anatomic resection,
including ligation of the lobar artery.
AUTOTRANSPLANTATION
• implanting multiple 1-mm slices of the spleen in the
omentum after splenectomy.
• This technique remains experimental ,role controversial

42. POST OPERATIVE CARE
• Recurrent bleeding in the case of splenorrhaphy or
new bleeding from missed or inadequately ligated
vascular structures should be considered in the
first 24-48 hours.
• Immunizations against Pneumococcus species as a
routine of postoperative management.(24 hours -
2 weeks)
• Some centers also routinely vaccinate for
Haemophilus and Meningococcus species

43. COMPLICATIONS
Early:
• Bleeding
• Acute gastric distension
• Gastric necrosis
• Rebleeding from splenic
bed
• Pancreatitis
• Subphrenic abscess
Late :
• OPSI (1-6WEEKS)
• DVT

44. DVT FOLLOWING SPLENECTOMY
• Splenectomy  thrombocytosis ( platelets)
 increases risk of DVT
• Portal vein thrombosis
• Abd pain, anorexia, thrombocytosis
• CT with IV contrast
• Prevention of DVT
• Sequential compression devises on legs
• Subcutaneous heparin

45. Opportunistic Post Splenectomy
Infection (OPSI)
• 3% of splenectomy patients
• Higher mortality in children (especially thalassemia and
SS)
• Decreased since use of pneumococcal vaccine
• Pneumonia or meningitis in half the cases
• Very rapid onset of symptoms and signs
• More than half die within 2 days of admission
• Within 2 years of splenectomy, especially children
Single daily dose of penicllin or amoxicillin for 2
yrs

46. FOLLOW UP OF POST
SPLENECTOMY PATIENTS
• revaccination with pneumococcal vaccine after 4-5 years
one time only.
• Patients should be warned about the increased risk of
postsplenectomy sepsis and should consider lifelong
antibiotic prophylaxis for invasive medical procedures and
dental work.
• Notify their doctor immediately of any acute febrile
illness
• Seek prompt treatment even after minor dog bite or
other animal bite.

47. LIVER INJURY
• The liver is the largest solid abdominal organ and is commonly
injured with abdominal trauma.
• It has a thin capsule with friable parenchyma and is found in a
fixed position between bony structures, which renders it
susceptible to crushing injuries.
• Its dual blood supply implies that injuries can result in
significant blood loss.
• The right lobe is larger than the left and is more frequently
injured.
• Segments 6, 7 and 8 are involved in 85% of injuries, commonly
due to compression against the fixed ribs, spine and posterior
abdominal wall.
• Given their pliable ribs and a weaker parenchymal connective
tissue network, children are more susceptible to blunt liver
injury.

48. DIAGNOSIS OF LIVER INJURY
• Focused assessment sonography in trauma (FAST)
performed in the emergency room by an experienced
operator can reliably diagnose free intraperitoneal fluid.
• Patients with free intraperitoneal fluid on FAST and
haemodynamic instability, and
• patients with a penetrating wound will require a
laparotomy and/or thoracotomy once active resuscitation
is under way.

49. CT Grading of liver trauma is based on the
American Association for the Surgery of
Trauma (AAST) injury scale

50. Management according to the Grade
Grade I,II
---minor injuries, represent 80-90% of all injuries, require
minimal or no operative treatment
Grade III-V
-- severe,require surgical intervention
GradeVI
--incompatible with survival

51. Non-Operative Management of Liver
Injury
• An absolute increase in the incidence of non operatively
managed liver injuries (NOMLI) is unequivocal.
• Multiple studies have shown that NOMLI is effective
Criteria for NOMLI
• No indications for laparotomy (physical examination
signs/symptoms or other injuries)
• Hemodynamically normal after resuscitation with crystalloid
• No injuries that preclude physical examination of the abdomen
(e.g., CHI, spinal cord injury)
• No transfusion requirements (PRBC)
• Constant availability of surgical and critical care resources

52. COMPLICATIONS OF NOMLI
• Biliary (bile peritonitis, bile leak, biloma, hemobelia..)
• Infection (liver abscess, necrosis, abdominal sepsis, SIRs)
• Abdominal compartment syndrome
• Hemorrhage
• Hepatic necrosis &/or Acalculous Cholecystitis
FAILURE OF NOMLI
• Usually attributed to reasons unrelated to liver injury
• Other injuries can be missed in a blunt trauma victims, such as:
• Bowel
• Pancreas
• Diaphragm
• Bladder
Which can lead to failure of NOMLI

53. OPERATIVE MANAGEMENT
INDICATIONS
BLUNTTRAUMA
• Hemodynamic instability
• Transfusion> 2 blood volume or
> 40 ml/kg
• Devitalized parenchyma
• Sepsis / biloma
PENETRATINGTRAUMA
• Exploratory lapratomy is
indicated in any penetrating
trauma in with peritoneal
penetration

54. OPERATIVE INTERVENTIONS
• Initial control of bleeding achieved with temporary
tamponade using packs, portal triad occlusion(Pringle
manoeuvre), bimanual compression of the liver or even
manual compression abdominal aorta above celiac
trunk
• If hemorrhage is unaffected by portal triad
occlusion(Pringle manoeuvre) by digital compression or
vascular clamp, major vena cava injury or atypical
vascular anatomy should be expected
Perihepatic packing
--Indication: coagulopathy, irreversible shock from blood loss
(10u), hypothermia(32C), acidosis(PH7.2), bilobar injury,large
nonexpanding hematoma, capsular avulsion, vena cava or
hepatic vein injuries

55. HEPATOTOMY WITH DIRECT SUTURE LIGATION
• using the finger fracture technique, electrocautery or an
ultrasonic dissector to expose damaged vessels and hepatic
duct which ligated , clipped or repaired
• low incidence of rebleeding, necrosis and sepsis
• effectives following blunt liver trauma requires further
evaluation
RESECTION DEBRIDEMENT
• removal devitalized tissue
• rapid compared with standard anatomical resection, which
are more time consuming and remove more normal liver
parenchyma
• reduced risk of post-op sepsis secondary hemorrhage and
bile leakage

56. MESH WRAPPING
• --new technique for grade III,IV laceration, tamponading large
intrahepatic hematomas
• --not indicated where juxtacaval or hepatic vein injury is
suspected
• Anatomical resection
• --reserved for deep laceration involving major vessels or bile
ducts, extensive devascularization and major hepatic venous
bleeding
OTHER OPERATIVE INTERVENTIONS
• Omental packing
• Intrahepatic tamponade with penrose drains
• Fibrin glue
• Retrohepatic venous injuries
--CompleteVascular isolation of the liver
--venovenous bypass
--Atriocaval shunting
• Liver transplantation

59. COMPLICATIONS
--Hemorrhage,sepsis
--Biliary fistula
--Respiratory problems
--Liver failure
--Hyperpyrexia
--Acalculous cholecystitis
--Pancreatic, duodenal or small bowel fistula

61. RENALTRAUMA
The kidney is injured in approximately 10%
of all significant blunt abdominal trauma.
Of those, 13% are sports-related when the
kidney, followed by testicle, is most
frequently involved.
However, the most frequent cause by far is
motor vehicle accident followed by falls
Renal lacerations and renal vascular injuries
make up only 10-15% of all blunt renal
injuries.
Isolated renal artery injury following blunt
abdominal trauma is extremely rare, and
accounts for less than 0.1% of all trauma
patients

62. DIAGNOSIS AND INITIAL EMERGENCY
ASSESSMENT
• Initial assessment of the trauma patient should include
securing the airway, controlling external bleeding, and
resuscitation of shock.
• In many cases, physical examination is carried out during
the stabilisation of the patient.
• Pre-existing renal abnormality makes renal injury more
likely following trauma.

63. The following findings on physical
examination could indicate possible renal
involvement:
• haematuria;
• flank pain;
• flank
ecchymoses;
• flank abrasions;
• fractured ribs;
• abdominal
distension;
• abdominal
mass;
• abdominal
tenderness.

64. INDICATION FOR FURTHER IMAGING
Gross haematuria
Microscopic
haematuria with
haemodynamic
instability
Persistant
microscopic
haematuria

65. CT WITH INTRAVENOUS
CONTRAST
Gold standard
Immediate and
delayed post
contrast images to
view collecting
system
Allows diagnosis
and staging
Images
abdomen and
retroperitoneum
Not for
haemodynamic
unstable patients

67. INTRAVENOUS PYELOGRAPHY
Unable to evaluate
abdomen and
retroperitoneum
Inadequate for
grading renal injury
Used in unstable pat
prior to surgery to
identify functioning
contralateral kidney

68. RENAL ANGIOGRAPHY
Delineates vascular
injury (intimal tears,
pseudoaneurysm,
AV fistulas)
Use when CT
equivocal and
continued
haemorrhage
Use for endo
vascular repair
(embolization,
stenting)

69. RENAL ULTRASOUND
Evaluation of
abd/pelvic
injury/fluid
acclumation
High false neg rate
for renal injury
Used in areas
without CT or for
follow up

70. AAST renal injury grading scale

72. NON-OPERATIVE MANAGEMENT OF RENAL
INJURIES
All grade 1 and 2 renal injuries can be managed non-operatively,
whether due to blunt or penetrating trauma.
Therapy of grade 3 injuries has been controversial, but recent studies
support expectant treatment
Patients diagnosed with urinary extravasation in solitary injuries can
be managed without major intervention and a resolution rate of >
90%.
In stable patients, supportive care with bed-rest,
hydration,antibiotics & continuous monitoring of vital signs until
haematuria resolves is the preferred initial approach.
The failure of conservative therapy is low (1.1%)

73. SURGICAL MANAGEMENT
- haemodynamic instability;
- exploration for associated injuries;
- expanding or pulsatile peri-renal haematoma identified during
laparotomy;
- grade 5 injury.
-pre-existing renal pathology requiring surgical therapy

74. OPERATIVE FINDINGS AND RECONSTRUCTION
The goal of renal exploration is control of haemorrhage and renal salvage.
the transperitoneal approach for surgery as access to the renal vascular
pedicle is then obtained through the posterior parietal peritoneum, which is
incised over the aorta, just medial to the inferior mesenteric vein.
Temporary vascular occlusion before opening Gerota’s fascia is a safe and
effective method during exploration and renal reconstruction as it tends to
lower blood loss and the nephrectomy rate.
The overall rate of patients who have a nephrectomy during exploration is
around 13%.
Generally in penetrating and gun shot injuries where renal reconstruction is
difficult

75. Renal reconstruction should be attempted in cases where the primary goal of
controlling haemorrhage is achieved and a sufficient amount of renal parenchyma
is viable.
Renorrhaphy is the most common reconstructive technique.
Partial nephrectomy is required when non-viable tissue is detected.
Watertight closure of the collecting system, if open, might be desirable,
although some experts merely close the parenchyma over the injured
collecting system with good results.
If the renal capsule is not preserved, an omental pedicle flap or peri-renal fat
bolster may be used for coverage .
In all cases, drainage of the ipsilateral retroperitoneum is recommended to provide
an outlet for any temporary leakage of urine.

76. Renovascular injuries are uncommon.
Non-operative management for segmental renal artery injury results in excellent
outcomes
Following blunt trauma, repair of grade 5 vascular injury is seldom if ever effective.
Repair could be attempted in which there is a solitary kidney or the patient has
sustained bilateral injuries. In all other cases, nephrectomy appears to be the
treatment of choice.
Angiography with selective renal embolisation for haemorrhage control is a
reasonable alternative to laparotomy provided that no other indication for immediate
surgery exists
The complication rate is minimal.
Effective for grade 4 injuries where conservative therapy failed.

77. FOLLOW UP
Repeat imaging within 2-4 days of significant renal.
Within 3 months of major renal injury, patients’ follow-
up should involve:
1. physical examination;
2. urinalysis;
3. individualised radiological investigation;
4. serial blood pressure measurement;
5. serum determination of renal function

78. COMPLICATIONS
EARLY ( < 1 MONTH)
BLEEDING.
INFECTION
PERI-NEPHRIC ABSCESS
SEPSIS
URINARY FISTULA
HYPERTENSION
URINARY
EXTRAVASATION
URINOMA
DELAYED
BLEEDING
HYDRONEPHROSIS
CALCULUS FORMATION
CHRONIC
PYELONEPHRITIS
HYPERTENSION
ARTERIOVENOUS FISTULA
HYDRONEPHROSIS
PSEUDOANEURYSMS.

80. PANCREATIC INJURY
• Pancreatic injuries caused by blunt trauma is exceedingly rare
(incidence 0.2‐12%)
• Clinical and laboratory findings are nonspecific
• Early diagnosis is critical in reducing morbidity and mortality
• Main pancreatic duct disruption is the greatest predictor for
complications.
• Mortality rates in blunt pancreatic injury range from 10% to 30%.
• Most deaths occur within the first 48 hours due to acute
haemorrhage of traumatized vasculature including:
- splenic vein
- portal vein
- inferior vena cava

81. MECHANISM OF INJURY
• Blunt pancreatic injury occurs with compression of
pancreas between the vertebral column and anterior
abdominal wall.
Adults – motor vehicle accidents
Adolescents –bicycle handlebar injuries
Infants –child abuse
• Pancreatic injury is more common in children and young
adults because of decreased protective intra‐abdominal
fat

82. DIAGNOSIS
SERUM
AMYLASE
LEVEL
Suggest only
pancreatic injury
Cannot predict or
correlate with the
degree of injury
SERUM LIPASE
LEVEL
nonspecific and a
poor indication of
injury
elevated levels may
provide a clue to a
severe injury
requiring further
investigation

83. ULTRASOUND
diagnosis of free
abdominal fluid
or gross damage
to the liver or
spleen can be
done
The pancreas is
not easily
identified
pancreatic
injuries,
parenchymal or
ductal, are
frequently
missed.
diagnosis of an
other intra-
abdominal injury
and need for an
urgent
explorative
laparotomy can
be done

84. MULTI‐DETECTOR CT
imaging modality of
choice in patients with
blunt abdominal trauma
excellent initial evaluation
for the detection and
characterization of solid
visceral organ injury
The sensitivity for
pancreatic injury is
between 67%‐85%
Pancreatic injuries tend to
be subtle, particularly
within the first 12 hours
after the traumatic event
MDCT provides improved
evaluation of pancreatic
duct integrity, which is of
the utmost importance in
triaging patients with
pancreatic injury

85. MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
high sensitivity and
specificity
Non invasive detection or
exclusion of pancreatic duct
trauma and pancreatic
specific complications
Unable to provide real-time
visualization of ductal
findings and extravasation

86. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
sensitivity and specificity of
100%
demonstrate clearly the site of
duct disruption and the grade
of duct injury
effective and safe non-
operative treatment tool
leakages of the pancreatic
duct, trans papillary stent
insertion might seal the injury
and stabilize it

88. TREATMENT ALGORITHM

89. NONOPER
ATIVE
MANAGE
MENT
absence of a
ductal injury
(grade I and II)
consists of
bowel arrest,
total parental
nutrition
serial imaging
with either CT
scans or
ultrasound to
follow injury
resolution

90. PROXIMAL
DUCT INJURY
Incomplete / complete
disruption of the MPD
without duct obstruction is
the best candidate for the
pancreatic duct stent
therapy
Transductal pancreatic
stent allows internal
drainage of the pancreatic
secretion and re-
establishment of duct
continuity
GRADE IV
INJURIESWITH
PDI
In stable patients,
pancreaticoduodenectomy
is the best definite
treatment
In unstable patients,
exploration and placing of
external drainage may be
the best choice for damage
control

91. DISTAL PANCREATIC INJURY WITH DUCT
INVOLVEMENT
wounds in the body or tail of the pancreas with an obvious duct injury or
transection of more than half the width of the pancreas
these grade III injuries are best treated by distal pancreatectomy
complete transection of the pancreatic body from the head, a distal
Pancreaticojejunostomy and closure of the proximal end of the pancreas
rupture

92. COMPLICATIO
NS
fistula
pancrea
tic
abscess
pseudocyst
formation
sepsis