Blunt pancreatic trauma: A persistent diagnostic conundrum?

Table 1 The American Association of Surgery for Trauma-organ injury scale pancreatic injury scale[25]

Grade	Description
I	Hematoma: Minor contusion without duct injury
	Laceration: Superficial laceration without duct injury
II	Hematoma: Major contusion without duct injury or tissue loss
	Laceration: Major laceration without duct injury or tissue loss
III	Laceration: Distal transection or parenchymal injury with duct injury
IV	Laceration: Proximal transection1 or parenchymal injury involving ampulla or bile duct
V	Laceration: Massive disruption of pancreatic head

¹Proximal injury is defined as lying to the right of the superior mesenteric vein.

Table 2 Computed tomography signs of pancreatic injury[9,10,12,27,38-41]

"Hard" signs/specific signs	"Soft" signs/suggestive signs
Fracture of the pancreas	Fluid separating the splenic vein from posterior aspect of pancreas
Pancreatic laceration	Fluid surrounding the superior mesenteric artery/(SMV cuff sign)
Focal or diffuse pancreatic enlargement/edema	Fluid in the anterior and posterior pararenal spaces
Pancreatic hematoma	Fluid in transverse mesocolon and lesser sac
Active bleeding/extravasation of intravenous contrast	Inflammatory changes in peripancreatic fat and mesentery
	Thickening of the left anterior renal fascia
	Delayed signs
	Pancreatic ductal dilatation
	Pseudocyst formation/peripancreatic fluid collection

SMV: Superior mesenteric vein.

Table 3 Treatment options for isolated pancreatic injuries based on the American Association of Surgery for Trauma pancreas organ injury scale[2,14,60]

AAST grade	Treatment options
I	Observation/conservative management
	Simple external drainage
	Omental pancreatorrhaphy and drainage
II	Observation/conservative management
	Simple external drainage
	Omental pancreatorrhaphy and drainage
III	Distal pancreatectomy +/- splenectomy
	Roux-en-Y distal pancreatojejunostomy
IV	Simple drainage in damage control situations
	Pancreatoduodenectomy (Whipple procedure)
	Distal Roux-en-Y pancreatojejunostomy
	Anterior Roux-en-Y pancreatojejunostomy
	Endoscopically placed stent
V	Pancreatoduodenectomy
	Drainage in damage control situations

AAST: American Association of Surgery for Trauma.