Pancreas Injury (Trauma to the Pancreatic Gland)
Pancreatic Trauma Definition
The term pancreatic trauma refers to injury of the pancreas, the elongated gland that sits in the upper middle quadrant of the abdomen. This can occur with blunt force trauma or sharp penetrating injuries. The pancreas is among the more commonly injured organ as it has very limited protection from the ribcage and is therefore quite exposed in the abdomen. A car accident injury or assault are two of the most common causes of pancreatic trauma. It is difficult to identify pancreatic trauma when it is very minor. Treatment in these cases of minimal injury is much easier. However, with moderate the severe trauma, it is very difficult to treat and manage the injured pancreas.
Pancreatic Trauma Effects
Normal Functioning Pancreas
There are many reasons why injury to the pancreas can be very serious and even life threatening in some instances. The pancreas is both an endocrine and exocrine gland. Its endocrine hormones like insulin enter the bloodstream directly where it helps to, among other activities, control the blood glucose levels. The pancreatic gland’s exocrine functions are to release digestive enzymes into ducts that then empty into the duodenum of the small intestine. These powerful digestive enzymes help with chemical digestion in breaking down fats, protein and carbohydrates.
There are many possible effects when the pancreas is injured. It depends on the extent and severity of the injury as well as the nature of the trauma.
- Pancreatic enzymes can digest tissue of the pancreas gland and leak into the abdominal cavity thereby damaging other organs.
- The pancreas may secrete excess amounts or little to no endocrine hormones such as insulin and glucagon thereby affecting blood glucose control.
- There may be profuse bleeding within the gland or into the abdominal cavity as the pancreas is highly vascularized. It also lies close to the major blood vessels like the aorta and inferior vena cava (IVC) which may also rupture leading to profuse blood loss.
- The pancreas may become severely inflamed and dysfunctional although there is no bleeding or damage of the gland tissue by digestive enzymes.
It is important to note that the pancreas does not exist in isolation. Firstly, it is surrounded by a number of different organs and structures in the abdominal cavity. With such diverse contents, injury to the abdominal cavity may often affect more than one organ or structure simultaneously. Similarly the pancreas impacts on various processes in the body and both directly and indirectly affects other organs. Pancreatic injury may therefore have a host of effects.
Pancreas Trauma Causes
Blunt Force Injury
Blunt trauma to the abdomen or back may not necessarily cause pancreatic injury only. The force dissipated in this type of injury may spread out and affect surrounding organs and structures of the abdomen simultaneously. It is seen with an abdominal blow as well as flank and mid-back injuries.
- Abdominal blows like a punch or seat belt injury.
- Falls are less likely causes of pancreas trauma unless a person falls on an object.
- Injury to the mid-back is more likely to affect the pancreas in children.
There are two types of penetrating injuries that can affect the pancreas.
- Stab wounds to the abdomen, flank or mid back. The pancreas may be the only organ that is affected.
- Gunshot wounds where the pancreas is affected along with other intra-abdominal organs.
Bleeding is common with penetrating injuries. When the injury is isolated to the pancreas, then most of the bleeding may be limited internally to the pancreas and peritoneal cavity. However, if the major blood vessels like the aorta or inferior vena cava (IVC) or other major organs are also affected, then bleeding through the wound (external hemorrhage) may be very severe.
Pancreas Trauma Symptoms
Injury to the pancreas can be symptomatic shortly after the traumatic event. This is more likely with blunt trauma. Penetrating trauma tends to present with overt bleeding among other symptoms.
- Redness and bruising may indicate the site of the injury in blunt trauma.
- Abdominal pain and back pain is common with pancreas injury although it is possible for a person to be pain free.
- Bleeding is obvious in penetrating injuries and clinical signs of significant blood loss may be present in severe cases.
- Peritonitis is inflammation of the inner lining of the abdominal cavity which may be caused by the injury itself or irritation with blood and digestive enzymes.
Since injury to the pancreas may cause inflammation and compromise the gland’s function, the following symptoms may also be present :
- Abnormalities of blood glucose levels
- Nausea and vomiting
- Loss of appetite
- Oily stools (steatorrhea)
Some of these symptoms may only appear several hours or days after the injury.
Pancreas Trauma Diagnosis
A clinical examination and medical history with note of the nature of the traumatic event if there are no external signs should raise the suspicion of pancreatic injury. However,the presentation of pancreas trauma can vary to a significant degree and may even mislead an experienced clinician. Therefore it should always be suspected with abdominal injury and excluded where possible with a range of tests.
- Amylase and lipase levels in the blood or peritoneal fluid that has been drained.
- Abdominal x-ray
- Computed tomography (CT) scan
- Magnetic resonance cholangiopancreatography (MRCP)
- Endoscopic retrograde cholangiopancreatography (ERCP)
An exploratory laparotomy may also be useful for a more definitive diagnosis of the extent of the pancreatic injury once the initial diagnosis is confirmed.
Pancreas Trauma Treatment
The treatment options for pancreatic trauma depends on multiple factors. Where pancreatic injury is suspected, although not overtly obvious and there is no signs of blood loss or other major symptoms, then a wait-and-watch approach can be adopted for at least 72 hours. Persistence of abdominal pain or the development of other symptoms thereafter should warrant immediate medical intervention. Patients may be need to be on total parenteral nutrition (TPN) where nutrients are delivered directly into the bloodstream. This gives the pancreas time to heal.
Surgery is usually necessary to treat traumatic pancreatic injury. A laparotomy may help identify the extent of the injury and repair damage to the ducts, tears in the pancreas capsule and drainage. Sometimes a severely damaged portion of the pancreas may be surgically removed (resection). Other features of pancreatic injury which may not require immediate treatment should be noted and monitored thereafter to ensure that it heals on its own. Total parenteral nutrition may be needed for period of time after surgery.
Pancreas Trauma Prognosis
The outlook of pancreatic trauma depends on the severity of the injury and how soon medical attention is sought. Minor injury usually has a good outcome. However, it is important to realize that pancreatic trauma can be life threatening and even the absence of major symptoms should not mislead both patient and doctor as to the seriousness of the condition. Major trauma to the pancreas requires surgery and ongoing medical supervision. Patients with pre-existing pancreatic disease or dysfunction have a poorer prognosis. In this day and age however, even major pancreatic trauma is not always life threatening if there is rapid medical intervention.