Radiol med DOI 10.1007/s11547-014-0410-3

EMERGENCY RADIOLOGY

Emergency contrast-enhanced ultrasonography for pancreatic injuries in blunt abdominal trauma Faqin Lv • Jie Tang • Yukun Luo • Yongkang Nie • Tong Liang • Ziyu Jiao • Zhihong Zhu • Tanshi Li

Received: 4 June 2013 / Accepted: 3 February 2014 Ó Italian Society of Medical Radiology 2014

Abstract Purpose The purpose of this study was to retrospectively investigate the application of emergency contrast-enhanced ultrasonography (CEUS) in blunt pancreatic trauma. Materials and methods Twenty-two consecutive patients with blunt pancreatic trauma were examined using CEUS from March 2007 to June 2012. The findings of CEUS were compared with those of contrast-enhanced computed tomography scans at level-1 diagnostic tests. Results Out of the 22 patients, 21 were diagnosed with blunt pancreatic injury using CEUS, including 8 patients with lesions in the neck of pancreas, 9 in the body, 3 in the tail and 1 in the head. The injury sites appeared as anechoic and/or hypoechoic perfusion defect regions with irregular borders in parenchyma and capsule on CEUS images. The lesion sizes measured by CEUS were 1.88 ± 0.81 cm, which were consistent with the 1.93 ± 0.77 cm measured by CT (p [ 0.05). Using CT as a reference standard, the detection rate of CEUS in blunt pancreatic trauma was 95.5 % (21/22).

Conclusions CEUS findings can be used to provide a reliable diagnosis for blunt pancreatic trauma. CEUS is thus promising in the assessment of blunt pancreatic trauma, especially in institutions where emergency CEUS is used as an initial diagnostic instrument. Keywords Pancreas  Trauma  Diagnosis  Contrastenhanced ultrasonography  Microbubbles

Introduction Pancreatic trauma is rare, occurring in about 0.2 % of patients with abdominal trauma [1]. However, it is accompanied with a high mortality rate of 70–80 % when injury involves the aorta, the superior mesenteric artery or the vena cava, which is adjacent to the pancreas. Since pancreas is a retroperitoneal organ, physical examination findings of abdominal pain or peritonitis are not reliable. Contusion of pancreas is easily missed. Moreover, missed

F. Lv  J. Tang (&)  Y. Luo  Z. Jiao Department of Ultrasound, Chinese People’s Liberation Army General Hospital, 28 Fuxing Road, 100853 Beijing, China e-mail: [email protected]

T. Liang Department of Ultrasound, Foshan Hospital of Traditional Chinese Medicine, Foshan, China e-mail: [email protected]

F. Lv e-mail: [email protected] Y. Luo e-mail: [email protected]

Z. Zhu  T. Li Department of Emergency, Chinese People’s Liberation Army General Hospital, Beijing, China e-mail: [email protected]

Z. Jiao e-mail: [email protected]

T. Li e-mail: [email protected]

Y. Nie Department of Radiology, Chinese People’s Liberation Army General Hospital, Beijing, China e-mail: [email protected]

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pancreatic injuries result in complications (severe haemorrhage, pancreatic fistula, and abscess) in 20–30 % of cases and mortality in more than 20 % [2]. Prompt diagnosis of pancreatic injuries has been challenging, particularly in blunt trauma patients. Diagnosis has relied on amylase levels, computed tomography (CT) scans, magnetic resonance imaging (MRI) and ultrasound (US), with various levels of success. Hyperamylasaemia is neither a sensitive nor specific marker for pancreatic injuries [3–5], even when isoenzyme levels are determined [6]. Serum amylase is neither sufficiently sensitive nor sufficiently specific to be used alone for the diagnosis of pancreatic injuries. Among patients with blunt pancreatic trauma, 65–75 % will manifest an elevated serum amylase. This number rises to 84 % following 3-h elapse between trauma and the time of measurement [2, 7, 8]. Undoubtedly, the best diagnostic tool for pancreatic trauma is CT [9]. Improved CT technology has reduced the risk of missed injuries [10]. MRI and CT are more sensitive than non-contrast US in detecting pancreatic injuries. Moreover, MR cholangiopancreatography (MRCP) can be more useful because it can demonstrate clear delineation of the duct and its integrity. However, CT and MR equipment is large and difficult to use at the bedside for early diagnosis, or at trauma scene for ‘point-ofcare’ diagnosis. Ultrasonic examinations are simple, convenient and radiation-free, which is ideal for bedside care in the emergency department. In fact, in recent years, US has been found helpful in the diagnosis of pancreatic injuries. It can show not only pancreatic enlargement and heterogeneous texture, but also retroperitoneal haematoma and fluid collections which are frequently secondary to pancreatic injuries. This capacity of US is important in the diagnosis and treatment of pancreatic trauma. However, conventional US cannot sufficiently display the location and severity of pancreatic lesions. The introduction of US contrast agents has led to an increase in the diagnostic accuracy of US in many organs, and the technique now has a wide range of applications [11–15]. In 2013, Cokkinos [16] reported that contrastenhanced US (CEUS) accurately defined organ injuries, capsular extension and even vascular injury with very good correlation with CT. The portability of CEUS makes it a good tool in trauma settings because examinations can be performed quickly at a patient’s bedside and benefits patients with either stable or unstable haemodynamics. The purpose of our study was to present the application of CEUS in diagnosing adult pancreatic injuries caused by blunt abdominal trauma.

Materials and methods This study was approved by the ethics committee of the Chinese People’s Liberation Army General Hospital and complies with the Health Insurance Portability and

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Accountability Act (HIPAA). In accordance with our institution’s regulations, informed consent for CEUS examination and use of related data for future research was obtained from each patient (or the patient’s relatives if he/ she was unconscious). Patients From March 2007 to June 2012 at two institutions equipped with modern laboratory, ultrasonographic and radiological equipment, a retrospective review of the charts of 22 consecutive patients with pancreatic injuries due to blunt abdominal trauma assessed by contrast-enhanced CT (CECT), was undertaken. The patients’ demographic data and the mechanism of injury were retrieved from the medical files. CEUS images or animations of the established cases of pancreatic injuries were retrieved from the picture archiving and communication systems (PACS) system of the ultrasound department. The 22 patients with established blunt pancreatic trauma included 19 men and 3 women aged 18–51 years (mean age, 28.6 ± 7.2 years). Seven patients had isolated pancreatic injury and 15 patients had complex injury, including 4 with hepatic injury, 6 with splenic injury, 2 with renal injury, 2 with hepatic and splenic injuries, and 1 with renal and splenic injuries. The mechanisms of injury included accidental fall, motorcycle crash, motor vehicle crash, and automobile-pedestrian collision. Ultrasound imaging The ultrasound contrast agent used in this study was SonoVue (Bracco, Milan, Italy), which is a second-generation contrast medium approved in China in 2003 for diagnostic imaging. The agent consists of stabilised microbubbles containing inert gas (sulphur hexafluoride, 8 lL/mL of solution), and is covered by a phospholipid membrane [17]. It is reconstituted with 5 mL of normal saline for a few seconds and is immediately administrable. There is no need for fasting or preliminary laboratory tests. The intravenous injection of this contrast agent can be repeated. Conventional US and CEUS were performed at the patient’s bedside in the emergency department, using a mobile Sequoia 512 machine (Siemens Medical Solutions, Mountain View, CA) or a portable CX50 system (Philips Medical Systems, Andover, MA). A 4V1 transducer with 2.0–4.5 MHz or a C5-1 transducer with 1–5 MHz was used in this study. CEUS was performed using contrast pulse sequencing (CPS) or using pulse inversion harmonic and energy-modulated technique at low acoustic power. The scan settings (including gain,

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scanning depth, and time gain control) were optimised on each target region independently. The focus was set to the deeper aspect of the organ being examined. SonoVue (0.025 mL/kg) was administered with a quick bolus through an antecubital vein. All the US and CEUS images and animations were stored in the PACS database of the ultrasound department and were available for review and interpretation. Image interpretation Two readers, with 7 and 5 years of experience with CEUS, respectively, and both with 3 years of experience with abdominal traumatic CEUS, independently reviewed the US and CEUS images and animations. They were blinded to each other. A lesion involving more than 50 % of the thickness of the pancreas indicated impending disruption [18], the diagnosis of pancreatic ductal injury was done indirectly by using CEUS. CT imaging Following the instruction of the emergency department, all patients were scanned within 1 h of admission by an emergency systematic CT scan after or before CEUS examination. The patients were studied with a 64-section CT scanner (Somatom Sensation 64; Siemens Medical Solutions, Erlangen, Germany) as follows: baseline scan, contrast-enhanced scan, 20 s delay after intravenous push of 30–50 mL of Ioversol 300 (Mallinckrodt Imaging Solutions, Hazelwood, MO, USA) at a rate of 2.5 mL/s. The CT scan parameters were slice thickness of 5 mm, collimation of 1.0 mm, gantry rotation speed of 1 s, table feeding speed of 15 mm/s, 120 kV and automatic mA setting. In cases of suspicion of active bleeding after the baseline scan, a late scan of the region of interest after 2 min was required to better document the extravasation. Statistical analysis The data were presented as descriptive or quantitative variables. Differences between group means were determined with analysis of variance (SyStat Ver 13.0, SPSS, Inc, Chicago, IL) with Chi-square test, consistency checking t or t test, where applicable. The level of statistical significance was set at a p value \0.05. Using CECT as a reference standard, CEUS value in the diagnosis of blunt pancreatic trauma was evaluated. Kappa values were calculated to assess inter-reader agreement on CEUS and US. Agreement was graded as poor (j \ 0.20), moderate (j = 0.20–0.40), fair (j = 0.40–0.60), good (j = 0.60–0.80), or very good (j = 0.80–1.00).

Results Evaluation of conventional US and CEUS Inter-reader agreement was good for conventional ultrasound (j = 0.795). Out of 22 patients with blunt pancreatic trauma, US showed 16 patients as having pancreatic enlargement and heterogeneous texture with unclear border (Fig. 1a). Peripancreatic liquid collections or haematoma occurred in seven patients, and their maximum diameter was 2.7 ± 1.2 cm. Inter-reader agreement was very good for CEUS (j = 0.934). Twenty-one of 22 patients were diagnosed with blunt pancreatic trauma using CEUS. These included 8 patients with lesions in the neck of pancreas, 9 in the body, 3 in the tail and 1 in the head. The pancreatic injury sites appeared as anechoic and/or hypoechoic perfusion defect regions with irregular borders and involved the pancreatic capsule in 21 patients on CEUS images in both the arterial and parenchymal phase (Fig. 1b). Their mean diameter was 1.88 ± 0.81 cm. CEUS did not present contrast medium extravasation or pooling in these patients, which indicated the absence of active bleeding. Six of 21 patients (28.57 %) were reported to have pancreatic ductal injuries accordingly as a lesion of more than 50 % of the thickness of pancreas can indicate likely disruption of the pancreatic ductal system [18]. Evaluation of CT scans CECT showed the lesion sites in pancreatic parenchyma as low-attenuation regions with irregular border (Fig. 1c). The mean diameter of lesions in 22 patients was 1.93 ± 0.77 cm, which was not different from the diameter measured by CEUS (p = 0.35). The injuries to the pancreatic tail reported by CECT in one case were missed by CEUS. Using CECT as a reference standard, the detection rate of CEUS in blunt pancreatic trauma was 95.5 % (21/ 22). Pancreatic ductal injuries were diagnosed by CECT in seven patients and accounted for 31.82 % (7/22), which was consistent with the 28.57 % rate (6/21) found by CEUS (p [ 0.05). Results of clinical follow-up Medical records were reviewed and the clinical follow-up findings in this group demonstrated 21 patients diagnosed by CEUS (Fig. 2a–c), and one patient missed by CEUS but diagnosed by CECT (Fig. 3a–c). One subtle injury site was not visualised clearly by CEUS and CECT until it slowly progressed. The patient (Fig. 4a–e), who was a 22-year-old man involved in an accidental collision, presented with homogenous pancreas parenchyma on emergency US, and

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Fig. 1 Conventional US, CEUS and CECT images in a 51-year-old man involved in a serious traffic accident. a Transverse conventional US shows pancreatic swelling and heterogeneous texture with unclear borders. b Contrast-enhanced transverse ultrasound image shows the injury site as an anechoic and hypoechoic perfusion defect area with

an irregular border in the pancreatic body (short arrows). Long arrows indicate swelling of the pancreatic body. c CECT scan of the patient shows the injury site as a heterogenous and low-attenuation region in the pancreatic body (arrows). P pancreas

a small contusion with ill-defined border in the pancreatic neck on CEUS performed within 0.5 h of admission. The injury region became larger, a thin pancreatic parenchyma remained and peripancreatic liquid collection appeared on the 16th day after trauma. These changes were also shown on the CECT images.

[15, 19–21]. It can help depict findings that are not accessible on conventional US, such as tissue hypoperfusion, nonperfusion, hyperaemia and contrast extravasation. In 2006, Valentino et al. [22] reported on a child with pancreatic trauma who was monitored by CEUS. They concluded that the pancreatic injury was well demonstrated by CEUS and, therefore, CEUS was used for follow-up until healing. The portability of CEUS makes it a good tool in trauma settings because examinations can be performed quickly at the patient’s bedside and benefits patients with either stable or unstable haemodynamics. Although a case study has been recently reported, the value of CEUS in pancreatic injuries has not yet been evaluated with doubleblind comparisons of CEUS and CECT. On the CEUS images and animations, pancreatic disruption or lacerations appear as anechoic and/or hypoechoic perfusion defect area in arterial and parenchymal phases, ideally with separated structures, which can be missed on conventional US images. Out of 22 patients with blunt pancreatic trauma, 21 were diagnosed with blunt pancreatic injury by using CEUS. CEUS presented a detection rate of 95.5 %, which is an exciting result. The

Discussion Pancreatic trauma, especially contusion, is a relative enigma, even in modern medical practice with advanced diagnostic technologies. Although hard to diagnose initially, most minor pancreatic injuries are relatively easy to cure. However, delayed diagnosis of mild pancreatic injuries could cause major therapeutic challenge to the medical team and potentially disastrous situations for the patients. Therefore, improving the sensitivity and specificity of diagnosing pancreatic injuries is essential for effective treatment. CEUS has largely improved US accuracy in detecting parenchymal organ injury after blunt abdominal trauma

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Fig. 2 Conventional US, CEUS and CECT images in a 38-year-old man involved in a serious traffic accident. a Transverse conventional US shows pancreatic swelling and heterogeneous texture with an illdefined border and peripancreatic liquid collection (arrow). b Contrast-enhanced transverse ultrasound image shows the injury site as an

anechoic and hypoechoic perfusion defect area with an irregular border in the pancreatic neck (arrow). c CECT scan image shows the injury site as a heterogenous and low-attenuation region in the pancreatic neck (arrow). P pancreas

ability of conventional US to display the traumatic pancreas injuries was limited. In this group, 16 patients were considered as having pancreas injuries by US on the basis of pancreas enlargement and heterogeneous texture. However, US did not confirm the lesion size and injury severity because it could not depict the lesion borders clearly. While CEUS has significantly improved the ability to visualise the peripancreatic space, the reason for this phenomenon may be the difference in blood supply, which makes it possible for CEUS to have a better view of pancreas and peripancreatic microcirculation perfusion. In 2013, Song et al. [23] reported that 40 pancreatic injuries were modelled in 40 Chinese miniature pigs and detected using CEUS and CECT. The detection rates of CEUS and CECT in pancreatic lesions were 85 and 82.5 %, respectively, and there was no significant difference (p [ 0.05). Compared with CEUS, CECT can provide valuable information to direct the clinical management of patients with pancreatic trauma. Cirillo et al. [24] stated that the reported sensitivity and specificity of CT scans in detecting pancreatic trauma was around 80 %. In the diagnosing pancreatic trauma, CECT has several advantages over

CEUS such as screening the entire abdomen and no limitations due to obesity, meteorism or subcutaneous emphysema. As a result, it has been popular among radiologists and surgeons. Moreover, CT has also been an important imaging modality in predicting the necessity for surgical or nonsurgical treatment. However, CT is not safe for haemodynamically unstable patients with blunt abdominal trauma. Our study demonstrated that CEUS enabled a bedside diagnosis and avoided the risks of transferring the patients. Of note, CEUS visualised pancreatic ductal injury, which was consistent with CECT. This study also showed that a CEUS examination for pancreatic injuries could be completed in less than 5 min using a single dose of contrast agent with operator’s skill and experience. The timely diagnostic capability of CEUS could contribute to a decrease in morbidity and mortality from pancreatic injuries. In diagnosing pancreatic injuries, CEUS has several advantages. (1) It is able to detect the lesion in pancreas parenchyma and capsule with excellent imaging characteristics. (2) It is portable, therefore it can be performed in the emergency room, CT department and at the bedside in

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Fig. 3 Conventional US, CEUS and CECT images in a 47-year-old woman involved in a serious collision accident. a Transverse conventional US shows normal pancreas as homogeneous texture without peripancreatic liquid collection. b Contrast-enhanced

transverse ultrasound image shows the pancreas as homogenous perfusion region with a regular border. c CECT scan image shows the injury site as a low-attenuation region in pancreatic tail (arrow). P pancreas

other departments. Especially for patients with unstable haemodynamics, CEUS is the preferred imaging method. (3) The examination is timely, with a room time \5 min. (4) CEUS examination can be simultaneously performed while performing other physical examination or resuscitation procedures. Some disadvantages of CEUS have also emerged in this study. (1) CEUS has similar limitations to conventional US, such as patient obesity, subcutaneous emphysema, etc. Moreover, CEUS lacks the panoramic quality of CT. (2) CEUS requires rapid and skilful diagnosis because the duration of a single CEUS examination is only 6–8 min. (3) Timely identification of major pancreatic ductal injury is imperative because delayed diagnosis is largely responsible for the high morbidity and mortality associated with blunt pancreatic trauma. Either CEUS or CECT indirectly diagnosed pancreatic ductal injury on the basis of a lesion involving more than 50 % of the thickness of pancreas, and the diagnostic accuracy are both lower. Endoscopic retrograde cholangiopancreaticography (ERCP) is the most

reliable diagnostic method to accurately define the continuity of the main pancreatic duct following pancreatic trauma, and it has been strongly suggested as an effective procedure for diagnosis and therapeutic interventions, including stent placement [25]. However, the invasive nature and associated complications are the major drawbacks of ERCP, limiting its use in unstable and uncooperative patients. Pancreatic injuries sustained by blunt abdominal trauma are extremely rare. However, once pancreatic injuries occur, they are often quite extensive and associated with injuries to other abdominal organs. CEUS should be considered for the initial detection of pancreatic trauma. It should not be intended as a substitute for CT, but as a selective possibility to boost the role of US in the initial screening of patients with pancreatic trauma. In conclusion, CEUS showed the site of pancreatic injury as anechoic and/or hypoechoic perfusion defect region with irregular borders in both the arterial and parenchymal phases, on which basis the diagnosis can be

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Fig. 4 Conventional US, CEUS and CECT images in a 22-year-old man involved in an accidental collision. a Transverse conventional US image of the pancreas indicates pancreatic homogeneous echogenicity without injury site. b Contrast-enhanced transverse ultrasound image shows a small hypoechoic perfusion area with an unclear border in the pancreatic neck (arrows). The body and tail of the pancreas present mild hypoechoic enhancement. c CECT scan image

of the patient shows the pancreas injury as a little low-attenuation region without clear border (arrows). d Conventional US shows that the pancreatic neck injury has become larger, the thin pancreatic parenchyma remains (arrow) and a peripancreatic liquid collection has appeared on the 16th day after trauma. e CECT scan image on the 16th day after trauma demonstrates the extension of injury in the pancreatic neck (arrow). P pancreas

established. CEUS, if performed appropriately and timely, was helpful and reliable in diagnosing and defining the severity of pancreatic injuries, demonstrated by CECT.

Conflict of interest Faqin Lv, Jie Tang, Yukun Luo, Yongkang Nie, Tong Liang, Ziyu Jiao, Zhihong Zhu, Tanshi Li declare no conflict of interest.

Acknowledgments We would like to express our gratitude to the Natural Science Foundation of China (Grant No. 81071279) and the Public Welfare Scientific Research Project of the Chinese Ministry of Health (Grant No. 201302017) for their financial supports for this project.

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Emergency contrast-enhanced ultrasonography for pancreatic injuries in blunt abdominal trauma.

The purpose of this study was to retrospectively investigate the application of emergency contrast-enhanced ultrasonography (CEUS) in blunt pancreatic...
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