Diagnosis and Classification of Pancreatic and Duodenal Injuries in Emergency Radiology

RadioGraphics 2008; 28:1591–1601

• Pancreatic and duodenal injuries after blunt abdominal trauma are rare; however, delays in diagnosis and treatment can significantly increase morbidity and mortality.

• Multidetector CT has a major role in early diagnosis of pancreatic and duodenal injuries.

• In duodenal injuries, differentiation between a contusion of the duodenal wall or mural hematoma and a duodenal perforation is vital.

• In pancreatic injuries, determination of involvement of the pancreatic duct is essential.

• The duodenum and pancreas can be injured simultaneously; isolated injuries are rare (<30%).

• Mortality for pancreatic injuries ranges from 9% to 34%;

for duodenal injuries it ranges from 6% to 29%.

Anatomy

D1

D2

D3

D4

•Involvement of a single portion of the duodenum

•Partial thickness, no perforation

I. Hematoma Laceration

•Involvement of more than one portion, disruption of <50% of the circumference

II. Hematoma Laceration

•Disruption of 50%–75% of the circumference of D2; disruption of 50%–100% of the circumference of D1, D3, and D4

III. Laceration

•Disruption of >75% of the circumference of D2 or involvement of the ampulla or distal common bile duct

IV. Laceration

•Massive disruption of the duodenopancreatic complex

•Devascularization of the duodenum

V. Laceration Vascular

Grade Injury Description

Scoring Duodenal Injury

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

Grade II duodenal injury. CT image obtained at a lower level shows thickening of the duodenal wall in the descending part . Adjacent to the duodenum is a small collection of extraluminal air, which indicates a small grade II laceration of the wall.

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. A subcapsular hematoma is present at the lower pole of the right liver lobe .

Grade III duodenal injury. Axial CT image shows thickening of the duodenal wall in the descending part. At the transition zone to the horizontal part, there is disruption of the wall. Additional findings include a retroperitoneal hematoma and hypoperfusion of the right kidney due to right renal artery occlusion.

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

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

• Fluid or a hematoma in the retroperitoneum, stranding of retroperitoneal fatty tissue, or pancreatic transection can be present in both conditions

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