Pancreas

Pancreas

Injuries to the pancreas are relatively rare and most often occur due to trauma to the upper abdomen. The pancreas can also become inflamed (pancreatitis) due to atraumatic causes, which are also worthy of consideration.

Anatomy and Function

The pancreas is an internal organ located in the upper left side of the abdomen. It has a relatively protected position due to the rib cage and spine surrounding it. Pancreatic functions include the production of hormones such as insulin and glucagon (involved in glucose homeostasis) and of pancreatic enzymes to help digest food. It is directly connected to the duodenum (small bowel) and the gall bladder and liver via the bile duct.

Pathology

Pancreatitis that is not due to trauma results from direct digestive enzyme release from injured cells. These pancreatic digestive enzymes cause inflammation in the pancreas and the surrounding region. Involvement of the pancreas can progress with lack of oxygen and obstruction of the pancreatic cells.

Epidemiology

Traumatic injury to the pancreas is unusual and seldom reported. Inflammation of the pancreas, or pancreatitis, has many causes other than traumatic injury. Atraumatic etiologies of acute pancreatitis (predominantly in adults) include

Gallstones

Insect or scorpion bites

Alcohol use

Procedures such as endoscopic retrograde cholangio-pancreatogram (ERCP)

Hypercalcemia

Viral infections

Hyperlipidemia

Various drugs

Hereditary factors

Biomechanics

Impact mechanics are important in determining the likelihood of injury. An object or body part (e.g., a foot or knee) striking a localized abdominal segment, such as the upper left quadrant, with a large deceleration or acceleration is the most common mechanism of injury. For instance, a bicycle fall where the handlebar twists and “spears” a child may be the presenting history. In this scenario, the handlebar compresses the pancreas against the spine, resulting in a pancreatic laceration. Body type may influence the risk of injury, as leaner individuals have greater susceptibility because of less fatty abdominal tissue to protect their internal organs from trauma. Acute pancreatitis in the pediatric population primarily results from direct traumatic injury, perhaps in part because most children have such a body type.

The duodenum (small bowel) is very close to the pancreas and is also commonly injured through localized trauma such as the impact from a bicycle handlebar. Bowel perforation (a hole in the bowel) is an important potential coexisting event and also should be included in the initial differential diagnosis as duodenal perforation can mimic acute pancreatitis in many ways.

Clinical Presentation

As with other internal organs, there is often a subtle presentation and minimal physical signs. A high index of suspicion is warranted as catastrophic outcomes (i.e., death) are possible if the symptoms go unrecognized. Patients can develop nausea, vomiting, and abdominal pain up to 48 hours after injury. Typically, the abdominal pain radiates to the back and is central in original localization.

The physical exam technique should follow the traditional medical model of inspection, palpation, percussion, and auscultation. There may be bruising evident in the area of injury on inspection. Lower rib fractures may also be present, hence tenderness to palpation in this location should alert one to potential underlying injury. Serial examination (repeating the exam periodically) of individuals suspected ...