pancreatic injuries are not common after blunt and penetrating trauma , but can be challenging to diagnose and manage . twenty - three year old man , injured during a fall from a motorcycle two days earlier , was admitted to department of surgery , university clinical centre tuzla because of suspicion of pancreatic trauma . immediately after hospitalization , patient underwent laboratory and radiological tests that revealed the existence of pancreatic trauma , so we opted for urgent surgical treatment . surgery and early postoperative course were normal and the patient was discharged on the ninth postoperative day . proper diagnosis and well - selected surgical treatment significantly increases the chances for recovery of these patients . pancreatic injuries are uncommon and can result from direct penetration into the organ or through the transmission of blunt force energy to the retroperitoneum . some studies report an incidence of 0.2% cases for blunt trauma up to 1.1% cases for penetrating trauma ( 1 ) . despite of low frequency of these injuries they are associated with significant morbidity and mortality , resulting in mortality rates of 23.4% and 30.2% for blunt and penetrating trauma , respectively ( 2 ) . the most commonly used system is the one devised by the american association for the surgery of trauma ( table 1 ) which is based on anatomic location of injury and status of pancreatic duct ( 3 ) . the diagnosis of pancreatic injuries is made by clinical examination , laboratory tests and imaging techniques such as ultrasound of the abdomen , contrast - enhanced ct scan , recap , or mcpc . the basic approach in the treatment of pancreatic injury is surgical and the choice of surgical procedure is govern by the location and the grade of injury . * proximal pancreatic injuries are injuries to the patient 's right of the superior mesenteric vein twenty - three year old man was hospitalized in general hospital tesanj due to injuries he sustained in motorcycle accident . on admission findings on ct scan of the brain , cervical spine and abdomen ( without contrast enhancement ) did nt suggest existence of any major injury . since the conducted diagnostic evaluation did nt verify the existence of traumatic changes , the patient was treated conservatively . however , two days after admission , his clinical status started to deteriorate . in order to evaluate the patient s status , control contrast - enhanced abdominal ct scan was made which suggested suspicion of a possible pancreatic injury . after that , patient was referred to university clinical center tuzla for further diagnostic and therapeutic evaluation . on admission to our hospital , physical examination revealed abdominal tenderness with signs of diffuse peritonitis . during preoperative evaluation laboratory tests and contrast - enhanced ct scan of the abdomen laboratory tests showed the elevation of leukocytes ( 17.42 , reference values 4.40 to 11.60 ) , c - reactive protein ( 180.5 , reference values 0.0 to 3.3 ) and mild elevation of serum amylase ( 618 u / l , reference values 23 to 135 ) . contrast - enhanced ct scan of the abdomen showed the presence of larger amounts of free fluid in the abdomen , and voluminous , inhomogeneous pancreas , transected at the body . ct scan also recorded laceration of the spleen , as well as diffuse imbibitions of adipose tissue and edema in the gastrocolic ligament ( contusion ) . given the clinical findings and the results of diagnostic evaluation , we decided for urgent surgical treatment . during surgery we found larger amount of free serohemoragic fluid inside the abdominal cavity , as well as incomplete transection of pancreas with disruption of the main duct to the patient s left of the superior mesenteric vein . according to aast organ injury scale it was grade iii injury of the pancreas . these intraoperative findings were consistent with ct scan we did during preoperative evaluation . with regard to intraoperative findings , we decided for distal pancreatectomy and splenectomy with external drainage ( figure 1 , 2 ) .  en bloc  resected distal pancreas and spleen remaining pancreas after distal pancreatectomy after surgery , the patient was admitted to the intensive care unit . the second postoperative day , the patient was haemodynamically and respiratory stable , moved from intensive care unit to the department of hepatobilliary and pancreatic surgery . on the eight postoperative day , the drains were removed and the patient was , on the next day , discharged home for outpatient follow - up . pancreatic injuries are relatively uncommon but , nevertheless , represent serious problem because of high morbidity and mortality rates that accompany them , with morbidity rates ranging between 45% and 60% , and mortality rates ranging between 23.4% and 30.2% ( 2,4 ) . the reason for these high morbidity and mortality rates can be attributed to delays in diagnosis and , consecutively , treatment . pancreatic enzymes are well known for their caustic nature , so every delay in management of pancreatic injuries results in massive systemic inflammation with subsequent poor outcomes . establishing the presence of pancreatic injury is a considerable challenge , as no single imaging modality has been found to highly effective . therefore , for early and timely diagnosis of pancreatic injury , a high index of suspicion must be maintained . patients with a history of acceleration / deceleration injury , forceful anterior compression of the abdomen and lower thoracic and upper lumbar vertebra fractures are at increased risk for pancreatic injury . a seatbelt sign across the upper and middle abdomen should suggest the possibility of serious intraabdominal injury ( 5 ) . in our case , the patient sustained pancreatic injury as a result of an impact of handlebars on the upper part of the abdomen . sometimes , abdominal pain and peritoneal signs take days to develop , which can be observed in our case , where more than 24 hours passed before abdominal pain and peritoneal signs developed . patients with elevations in white blood cell count , serum amylase , or lipase require further investigation . recent studies report that elevated serum amylase and lipase levels , obtained 6 hours after trauma , can be used as reliable indicator of pancreatic injury , although non diagnostic within 6 hours or less after trauma ( 6 ) . if the abdominal examination initially yields equivocal or unreliable results in a haemodynamically stable patient with hyperamylasemia , a contrast enhanced abdominal ct scan should be done . although it can indicate pancreatic injury , ct scan is only moderately sensitive and can underestimate or miss pancreatic injury . the sensitivity for detecting parenchymal or ductal injury ranges between 60% and 68% ( 7,8 ) . abdominal ct scan is unreliable in diagnosing pancreatic duct injury and should not be used to guide therapy ( 9 ) . for those patients endoscopic retrograde cholangiopancreatography may be helpful , as it is the best modality for imaging the pancreatic duct , and can be used as therapeutic procedure to stent lacerated ducts in selected patients ( 10,11 ) . minor pancreatic injuries ( grade i ) in haemodynamically stable patients can be treated conservatively ( 12 ) . however , the mainstream of therapy for pancreatic injuries is surgical . minor pancreatic contusions , hematomas , and capsular lacerations ( grade i ) , as well as lacerations of the pancreatic parenchyma without major duct disruption or tissue loss ( grade ii ) , are treated with hemostasis and adequate external drainage . distal pancreatic injuries with disruption of the main pancreatic duct ( grade iii ) are best treated with distal pancreatectomy . injuries to the pancreatic head , grade iv and v are the most difficult to manage . in rare instances when the proximal duct is injured in the absence of concomitant duodenal / ampullary injury , extended distal ( subtotal ) pancreatectomy or roux - en - y pancreaticojejunostomy ( tail - sparing ) may be performed . massive destruction of the pancreatic head , or combined pancreatic and duodenal injuries are best treated with pancreaticoduodenectomy ( 13,14 ) . in our case , physical examination , laboratory tests and contrast - enhanced ct scan of the abdomen , suggested pancreatic injury with duct disruption , so we decided for urgent surgical treatment which resulted in full recovery of the patient . pancreatic injuries are not frequent , but they have an important place in the abdominal trauma considering the high level of morbidity and mortality that is associates with these injuries . the diagnosis of pancreatic injuries is not simple and requires a high index of suspicion . delay of a timely diagnosis significantly reduces the chances of adequate treatment , thereby increasing the morbidity and mortality . the main stream of therapy for pancreatic injuries is surgical , and is determined by the grade and location of injury . since the majority of the pancreatic injuries are milder grade , most of the surgical interventions end with an exploration and external drainage . however , in cases in which pancreatic laceration with main duct injury is documented , some of the surgical resection procedures are indicated , such as distal pancreatectomy ( with or without splenectomy ) or cephalic duodenopancreatectomy ( trauma whipple ) .
introduction : pancreatic injuries are not common after blunt and penetrating trauma , but can be challenging to diagnose and manage.case report : twenty - three year old man , injured during a fall from a motorcycle two days earlier , was admitted to department of surgery , university clinical centre tuzla because of suspicion of pancreatic trauma . immediately after hospitalization , patient underwent laboratory and radiological tests that revealed the existence of pancreatic trauma , so we opted for urgent surgical treatment . 
 surgery and early postoperative course were normal and the patient was discharged on the ninth postoperative day.conclusion:proper diagnosis and well - selected surgical treatment significantly increases the chances for recovery of these patients .