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CASE SCENARIO

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A 45-year-old man with no significant past medical history was a restrained driver in a motor vehicle collision. Paramedics report significant damage to the vehicle, including a deformed steering wheel, with no airbag deployment. He is hemodynamically appropriate on arrival in the emergency room, but complains of epigastric pain.

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On primary survey, his airway is patent, his breath sounds are equal bilaterally, and pulses are easily palpable and symmetric. His physical examination is significant for abdominal tenderness in the bilateral upper quadrants. His abdomen is otherwise soft with no guarding or rebound. His extremities are warm without any obvious deformities.

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A portable chest x-ray is within normal limits. A focused assessment with sonography for trauma (FAST) examination shows no free fluid in the abdomen. Lab work reveals an elevated white blood cell count of 13, normal hematocrit, normal coagulation profile, and an elevated serum amylase at 160.

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EPIDEMIOLOGY

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Pancreatic injury has been reported in 1% to 5% of all cases of blunt abdominal trauma and up to 12% of penetrating trauma.1, 2, 3, and 4 Common mechanisms include motor vehicle collisions with or without seatbelt use, bicycle “over the handlebars” accidents, assaults, and gunshot and stab wounds. Likely due to its retroperitoneal location (see the below), isolated pancreatic trauma is rare, and other intra-abdominal injuries are found in >90% of cases.5 The organs most commonly injured concurrently include the liver, spleen, duodenum, and small intestine.

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Although relatively uncommon, pancreatic injuries are associated with a high mortality (10%–30%) and morbidity (30%–60%).6 Early mortality in these patients is often secondary to hemorrhage, while later mortalities are frequently due to infection, associated injuries, and sequelae of pancreatic leaks. A delay in diagnosis of >24 hours has been associated with a threefold increase in mortality.7

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PATHOPHYSIOLOGY

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The pancreas is a retroperitoneal organ with both exocrine and endocrine functions. It is divided into five parts including the head, uncinate process, neck, body, and tail (Figure 27–1). The pancreatic head sits in the curve of the duodenum to the right of midline at the level of the second lumbar vertebral body. The neck separates the head from the body and is anterior to the superior mesenteric artery (SMA) and the confluence of the portal vein (PV) with the superior mesenteric vein (SMV) and the splenic vein. The body of the pancreas is anterior to the aorta and directly in front the first lumbar vertebra (L1), a position that makes it particularly vulnerable to blunt abdominal trauma. The body crosses the midline and merges without a discernible junction with the pancreatic tail, which extends to the hilum of the spleen. Although ductal anatomy can vary, the main pancreatic duct of Wirsung runs the length of the pancreas. The accessory duct of Santorini usually branches from the ...

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