Lecture notes for medical students

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. Format

3. Format
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.

5. Introduction & History.
• relatively protected position high in the
retroperitoneum, is infrequently injured in
typical blunt injuries.
• many blunt pancreatic injuries are not
immediately recognized and consequently
end up causing higher morbidity and
mortality rates
• Conversely, penetrating abdominal
trauma—by its very nature usually
mandating emergency exploration—more
frequently includes pancreatic injury.

6. Introduction & History.
• But even physical visualization and
examination of the pancreas in the operating
room may miss an isolated ductal injury to
the pancreas without adjunctive tests.

7. Relevant Anatomy

8. Relevant Anatomy
•

9. Relevant Anatomy
• Located in a relatively protected area of the
abdominal cavity, from blunt trauma.
• the anatomic position of the pancreas
neither protects nor increases the risk from
penetrating injury.
• The proximity of vascular structures to the
head of the pancreas-
– increases the morbidity and mortality rates of
pancreatic injury.
– Makes repair difficult and risky.

10. Aetiology

11. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic
• Psychosomatic

12. Grading

13. Grading

14. Grading
•

15. Clinical Features

16. Clinical Features
• Demography
• Symptoms
• History
• Signs
• Prognosis
• Complications

17. Demography

18. Demography
• The overall rate of blunt pancreatic injury
is low.
• 10th most injured organ compared to other
organs
• Of 100 patients with blunt trauma, fewer
than 10 will have a documented pancreatic
injury.
• 20-30% of all patients with penetrating
traumas.
• a pancreatic injury is rarely a solitary
injury.

19. Symptoms

20. Symptoms
• symptom free early in the postinjury time frame
and even silent in many cases.
• dull epigastric pain or back pain,
• Symptoms of injury to other structures commonly
mask or supersede that of pancreatic injury,
• high degree of clinical awareness is necessary to
ensure that pancreatic injuries are not overlooked
or missed, either early in the course of trauma or
later in the ICU when the patient is not clinically
improving as expected.

21. Indications

22. Indications
• In patients experiencing blunt trauma, CT scans
provide the best overall method for diagnosis and
recognition of a pancreatic injury.
• Retroperitoneal hematoma, retroperitoneal fluid,
free abdominal fluid, and pancreatic edema
frequently accompany injuries to the pancreas.
• In patients with penetrating trauma, visualization
of perforation, hemorrhage or fluid leak (eg, bile,
pancreatic fluid), or retroperitoneal hematoma
around the pancreas suggests the need for further
evaluation.
• magnetic resonance cholangiopancreatography
(MRCP)

23. Prognosis

24. Prognosis
• Outcome from minor and isolated
pancreatic injury is usually quite good.
Complications are rare, and functional
outcome is excellent.
• Outcome from severe pancreatic injury is
much poorer overall than with other organ
injuries. This outcome is primarily due to
the frequent presence of associated life-
threatening injuries and the unforgiving
nature of the pancreas, both for missed
injury and after major emergency operative
intervention.

25. Investigations

26. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

27. Laboratory Studies

28. Laboratory Studies
• Blood work is notoriously unreliable
• Elevation in amylase levels is suggestive of
pancreatic injury or inflammation but is not
diagnostic.
• Lipase levels are no more specific for
pancreatic injury.
• Amylase detected in diagnostic peritoneal
lavage (DPL) fluid is much more sensitive
and specific for pancreatic injury than blood
or serum amylase determinations.

29. Diagnostic Studies

30. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

31. Diagnostic Studies
Imaging Studies
• X-Ray-penetrating trauma-foreign bodies
such as bullet fragments and projectile-
induced bony injury.
• CT in hemodynamically stable.
• MRI – is best.
• Endoscopy ERCP in selected cases
• Nuclear scan.

32. Diagnostic Studies
Imaging Studies
• An unstable patient should never be sent to
to CT scan or MRI.
• If proceeding for laparotomy there is no
need for CT MRI
• Intraoperative cholangiograms and
pancreatic ductograms provide information
regarding the status of the injured pancreas
when direct visualization is not helpful.

33. Management

34. Management
• The standard of care in penetrating injuries
is still operative exploration.
• Observation in select blunt injuries to the
pancreas.
• Therapy wasshould be based on injury
grade and location.

35. Non Operative Therapy

36. Non Operative Therapy
• Capsular tears, superficial lacerations, bullet
wounds of the body or tail, small
contusions, or hematomas should be
visualized and documented; however, they
should not be surgically explored unless
ductal injury is suspected.
• intact ductal systems may be drained and
observed.
• Soft closed suction drains

37. Operative Therapy

38. Operative Therapy
• Patients with ductal injury usually require
resection of the tail and body
• Continued drainage with high amylase
levels persisting beyond 48-72 hours is
highly suggestive of a missed ductal injury.

39. Penetrating trauma

40. Penetrating trauma
• As with blunt trauma, examination and
peripancreatic drainage is the most common
intervention
• Resection of the tail or body
• injuries to the head and neck of the pancreas
may require more creative and more
difficult operative therapies.
• Isolated minor ductal damage can
occasionally be stented operatively or by
the interventional radiologist

41. Futuristic

42. Futuristic
• CT cholangiopancreatography
• Multidetector CT scanners and MRCP are
emerging as more sensitive diagnostic tools

43. Complications

44. Complications
• Fistula formation
– good nutrition and supportive care
– ERCP
• Delayed complications
– recurrent pancreatitis
– pancreatic pseudocysts
– splenic artery aneurysm
– endocrine or exocrine insufficiency

45. Guidelines

46. Guidelines
• Visit American association for surgery of
trauma website.

47. Take home messages

48. Take home messages
• Penetrating injury- laparotomy
• Unstable patient- laparotomy
• Stable patient - CT abdomen
• high degree of suspicion
• parenchymal injury/minor injuries-- wide
drainage
• ductal injury distal pancreatectomy

49. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

51. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

52. Get this ppt in mobile

53. Get my ppt collection
• https://www.slideshare.net/drpradeeppande/
edit_my_uploads
• https://www.dropbox.com/sh/x600md3cvj8
5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl
=0
• https://www.facebook.com/doctorpradeeppa
nde/?ref=pages_you_manage