Duodenum and Pancreas Injuries
The duodenum and pancreas are somewhat protected by the contents of the gut but when they are injured, it can be a real challenge to manage. There are a lot of complications with these injuries and not many trauma surgeons have the training or experience to handle them. Duodenal or pancreatic injuries are found in only 3-6 percent of patients who undergo an exploratory surgery after trauma. These two structures can be injured by blunt or penetrating trauma.
Most injuries to the pancreas and duodenum do not exist in isolation. They are too close to other abdominal structures that are also injured during the same trauma. Other organs injured include the liver, the right kidney, the great vessels of the abdomen, the stomach, the small bowel, and the gallbladder. When both the pancreas and duodenum are injured together, the rate of death doubles when compared to either one of these organs injured alone.
Three fourths of all patients who die from pancreas or duodenal injures die within the first 48 hours, usually from severe hemorrhage or from a neurological injury. Predictors of survival include young age, having less brain injury and less shock. Up to half of all people who are treated with an initial operation to repair these organs have some kind of complication. If the diagnosis is delayed, the rate of death is much higher.
The duodenum and pancreas are closely connected to other abdominal organs. The duodenum is located very near the back of the individual, behind other abdominal structures. Some of the duodenum lies directly over the vertebral column. The liver and gallbladder cover much of the duodenum. The pancreas extends from the right side of the abdomen, near the liver all the way over to the area of the stomach.
The duodenum is important in vitamin and mineral absorption as well as the processing of food. If a part of the duodenum has to be removed, the individual may suffer from a lack of B12 absorption as well as other malabsorption problems. The pancreas is important in the production of insulin as well as in the making of digestive enzymes that help breakdown food for absorption.
Diagnosis of Pancreatic and Duodenal Injuries
As many of these injuries are from penetrating trauma, they are discovered when the patient’s abdomen is opened up following a penetrating trauma. Because these are deeply contained organs, other organs, such as the transverse colon, have to be moved out of the way in order to see them properly. Sometimes the pancreas has to be cut in two during the procedure in order to stop bleeding and to see the entire pancreas properly.
Blunt trauma injuries to the duodenum and pancreas are harder to diagnose, especially if the patient has a normal blood pressure and no signs of hemorrhaging. They are often injured whenever there is blunt-force injury to the upper portion of the abdomen.
The focused abdominal sonogram for trauma or FAST examination can tell if there is blood in the abdominal spaces but doesn’t tell where the bleeding is coming from. It does, however, spur the surgeon on to do an open abdominal surgery to look for the source of the bleeding, which may be coming from the pancreas or duodenum.
CT scanning is probably the best way to diagnose a pancreatic or duodenal injury. Signs of perforation of the duodenum include air in the abdominal space outside of the duodenum. There can be evidence of a blood clot in the wall of the duodenum on CT scanning. Dye can be instilled into the duodenum prior to CT scanning. If dye is found outside the duodenum, then a perforation can be suspected. The CT scan can also show fractures of the pancreas, along with active bleeding. If the pancreas is just bruised, however, it may not be noticed on CT scan.
Most of the complications of pancreatic injury happen if the pancreatic duct is injured. The pancreatic duct is the duct that carries pancreatic juices from the main body of the pancreas to the duodenum for processing of food. There are special techniques including an MRI evaluation that can tell if the duct is disrupted. Contrast material (dye) can be put inside the duct and x-rayed to see if the duct is perforated or ruptured.
The treatment of pancreas and duodenal injuries depend on the severity of the injury. Low grad injuries to the duodenum that are not actively bleeding do not need surgery. Most of these blood clots will resolve in just three weeks. The main complication of a blood clot in the duodenal wall is that it can block the outflow of the stomach contents, leading to a backup of food into the stomach. In such cases, surgery might be indicated.
About 75 percent of all duodenal lacerations come from penetrating trauma. These are identified at the time of surgery to see what is wrong inside the abdomen after a penetrating trauma. Simple lacerations of the duodenum can simply be sutured shut. In higher grade injuries, the treatment is more complex and involves removal of dead tissue and control of bleeding until a definitive repair can be done at another surgical time.
The main problem in pancreatic injuries is an injury to the pancreatic duct. Bruising of the pancreas without disruption of the pancreatic duct can be treated without having to do surgery. Sometimes part of the pancreas has to be removed but it has been found that removal of all but a small part of the pancreas maintains the ability of the pancreas to still perform its usual functions. If more than 90 percent of the pancreas is removed, the pancreas will not function normally.
Complications of Pancreatic and Duodenal Trauma
Those with injuries to the pancreas and duodenum that don’t die in the first 48 hours later die from blood infections or multiple organ failure. The main complications of injuries to the pancreas and duodenum include the following:
- Hemorrhage—this is often associated with early deaths from trauma.
- Secondary hemorrhage
- Pancreatic fistula—this is a draining hole coming from the pancreas to the outside of the body or to another organ within the body. These are usually treated with draining of the fistula until it heals itself.
- Duodenal fistula and stricture—this happens when the suturing of the duodenum is too tight and the duodenum narrows, causing an obstruction at the level of the injury.
- Abdominal abscess
- Pancreatitis—the pancreas might become inflamed after being injured, resulting in pancreatitis.
- Pancreatic insufficiency—this can happen when too much of the pancreas has been removed, leaving too little pancreatic tissue to do the functions of a normal pancreas.