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Blunt Trauma of the Pancreas and Biliary Tract: A Multimodality Imaging Approach to Diagnosis¹

¹ From the Department of Radiology, Boston University Medical Center and Boston University, Mass. Presented as an education exhibit at the 2003 RSNA scientific assembly. Received January 7, 2004; revision requested February 17 and received March 25; accepted March 29. All authors have no financial relationships to disclose. Address correspondence to A.G., Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA 02215 (e-mail: agupta@bidmc.harvard.edu).

View larger version (122K): [in a new window]   Figure 1a.  Fracture of the pancreatic neck in a 35-year-old woman after a motor vehicle collision. (a, b) Axial contrast-enhanced CT scans show extensive liver lacerations (a) and a fracture line at the pancreatic neck (arrowhead in b). (c) Transverse ultrasonographic (US) image shows fluid separating the pancreatic fragments at the fracture site (arrowhead). (d) Image from endoscopic retrograde cholangiopancreatography (ERCP) shows a large collection of extravasated contrast material (arrowheads), which indicates disruption of the pancreatic duct.

View larger version (117K): [in a new window]   Figure 1b.  Fracture of the pancreatic neck in a 35-year-old woman after a motor vehicle collision. (a, b) Axial contrast-enhanced CT scans show extensive liver lacerations (a) and a fracture line at the pancreatic neck (arrowhead in b). (c) Transverse ultrasonographic (US) image shows fluid separating the pancreatic fragments at the fracture site (arrowhead). (d) Image from endoscopic retrograde cholangiopancreatography (ERCP) shows a large collection of extravasated contrast material (arrowheads), which indicates disruption of the pancreatic duct.

View larger version (106K): [in a new window]   Figure 1c.  Fracture of the pancreatic neck in a 35-year-old woman after a motor vehicle collision. (a, b) Axial contrast-enhanced CT scans show extensive liver lacerations (a) and a fracture line at the pancreatic neck (arrowhead in b). (c) Transverse ultrasonographic (US) image shows fluid separating the pancreatic fragments at the fracture site (arrowhead). (d) Image from endoscopic retrograde cholangiopancreatography (ERCP) shows a large collection of extravasated contrast material (arrowheads), which indicates disruption of the pancreatic duct.

View larger version (108K): [in a new window]   Figure 1d.  Fracture of the pancreatic neck in a 35-year-old woman after a motor vehicle collision. (a, b) Axial contrast-enhanced CT scans show extensive liver lacerations (a) and a fracture line at the pancreatic neck (arrowhead in b). (c) Transverse ultrasonographic (US) image shows fluid separating the pancreatic fragments at the fracture site (arrowhead). (d) Image from endoscopic retrograde cholangiopancreatography (ERCP) shows a large collection of extravasated contrast material (arrowheads), which indicates disruption of the pancreatic duct.

View larger version (131K): [in a new window]   Figure 2a.  Fracture of the pancreatic neck in a 36-year-old woman after a motor vehicle collision. (a) Axial CT scan obtained with intravenous contrast material shows separation of the pancreatic head from the body and tail along with extravasation of contrast material (arrowheads), which indicates active hemorrhage. (b) ERCP image shows active extravasation of contrast material (arrowheads) due to transection of the pancreatic duct. (c, d) Intraoperative photographs show the pancreatic fracture (arrowheads in c) and anastomosis of the pancreatic tail with the jejunum (arrowheads in d). Note the pancreatic head (arrow in d), which has been oversewn at the site of fracture. (e) Axial CT scan obtained with intravenous contrast material after surgical repair shows anastomosis of the pancreatic tail with the jejunum (arrowhead). Note the pancreatic head fragment (arrow).

View larger version (104K): [in a new window]   Figure 2b.  Fracture of the pancreatic neck in a 36-year-old woman after a motor vehicle collision. (a) Axial CT scan obtained with intravenous contrast material shows separation of the pancreatic head from the body and tail along with extravasation of contrast material (arrowheads), which indicates active hemorrhage. (b) ERCP image shows active extravasation of contrast material (arrowheads) due to transection of the pancreatic duct. (c, d) Intraoperative photographs show the pancreatic fracture (arrowheads in c) and anastomosis of the pancreatic tail with the jejunum (arrowheads in d). Note the pancreatic head (arrow in d), which has been oversewn at the site of fracture. (e) Axial CT scan obtained with intravenous contrast material after surgical repair shows anastomosis of the pancreatic tail with the jejunum (arrowhead). Note the pancreatic head fragment (arrow).

View larger version (97K): [in a new window]   Figure 2c.  Fracture of the pancreatic neck in a 36-year-old woman after a motor vehicle collision. (a) Axial CT scan obtained with intravenous contrast material shows separation of the pancreatic head from the body and tail along with extravasation of contrast material (arrowheads), which indicates active hemorrhage. (b) ERCP image shows active extravasation of contrast material (arrowheads) due to transection of the pancreatic duct. (c, d) Intraoperative photographs show the pancreatic fracture (arrowheads in c) and anastomosis of the pancreatic tail with the jejunum (arrowheads in d). Note the pancreatic head (arrow in d), which has been oversewn at the site of fracture. (e) Axial CT scan obtained with intravenous contrast material after surgical repair shows anastomosis of the pancreatic tail with the jejunum (arrowhead). Note the pancreatic head fragment (arrow).

View larger version (109K): [in a new window]   Figure 2d.  Fracture of the pancreatic neck in a 36-year-old woman after a motor vehicle collision. (a) Axial CT scan obtained with intravenous contrast material shows separation of the pancreatic head from the body and tail along with extravasation of contrast material (arrowheads), which indicates active hemorrhage. (b) ERCP image shows active extravasation of contrast material (arrowheads) due to transection of the pancreatic duct. (c, d) Intraoperative photographs show the pancreatic fracture (arrowheads in c) and anastomosis of the pancreatic tail with the jejunum (arrowheads in d). Note the pancreatic head (arrow in d), which has been oversewn at the site of fracture. (e) Axial CT scan obtained with intravenous contrast material after surgical repair shows anastomosis of the pancreatic tail with the jejunum (arrowhead). Note the pancreatic head fragment (arrow).

View larger version (132K): [in a new window]   Figure 2e.  Fracture of the pancreatic neck in a 36-year-old woman after a motor vehicle collision. (a) Axial CT scan obtained with intravenous contrast material shows separation of the pancreatic head from the body and tail along with extravasation of contrast material (arrowheads), which indicates active hemorrhage. (b) ERCP image shows active extravasation of contrast material (arrowheads) due to transection of the pancreatic duct. (c, d) Intraoperative photographs show the pancreatic fracture (arrowheads in c) and anastomosis of the pancreatic tail with the jejunum (arrowheads in d). Note the pancreatic head (arrow in d), which has been oversewn at the site of fracture. (e) Axial CT scan obtained with intravenous contrast material after surgical repair shows anastomosis of the pancreatic tail with the jejunum (arrowhead). Note the pancreatic head fragment (arrow).

View larger version (106K): [in a new window]   Figure 3a.  Large pseudocyst due to transection of the pancreatic duct in a 37-year-old man several weeks after blunt trauma. (a) Axial contrast-enhanced CT scan shows a large, loculated fluid collection (*) within the lesser sac, between the fragments of the pancreatic head and body. (b) Axial contrast-enhanced CT scan obtained after percutaneous drainage shows a catheter (arrowheads) within the pseudocyst. (c) ERCP image shows extravasation of contrast material (arrowheads), thus confirming the transection of the pancreatic duct. Note the drainage catheter within the collection (arrow). A stent was placed in the pancreatic duct during endoscopy (not shown). (d) Axial contrast-enhanced CT scan obtained several weeks after drainage shows resolution of the pseudocyst. Note the stent in the pancreatic duct (arrowhead) and the drainage catheter at the former site of the pseudocyst (arrow). (e) ERCP image obtained the same day as d shows no extravasation of contrast material, thus confirming the integrity of the pancreatic duct.

View larger version (102K): [in a new window]   Figure 3b.  Large pseudocyst due to transection of the pancreatic duct in a 37-year-old man several weeks after blunt trauma. (a) Axial contrast-enhanced CT scan shows a large, loculated fluid collection (*) within the lesser sac, between the fragments of the pancreatic head and body. (b) Axial contrast-enhanced CT scan obtained after percutaneous drainage shows a catheter (arrowheads) within the pseudocyst. (c) ERCP image shows extravasation of contrast material (arrowheads), thus confirming the transection of the pancreatic duct. Note the drainage catheter within the collection (arrow). A stent was placed in the pancreatic duct during endoscopy (not shown). (d) Axial contrast-enhanced CT scan obtained several weeks after drainage shows resolution of the pseudocyst. Note the stent in the pancreatic duct (arrowhead) and the drainage catheter at the former site of the pseudocyst (arrow). (e) ERCP image obtained the same day as d shows no extravasation of contrast material, thus confirming the integrity of the pancreatic duct.

View larger version (123K): [in a new window]   Figure 3c.  Large pseudocyst due to transection of the pancreatic duct in a 37-year-old man several weeks after blunt trauma. (a) Axial contrast-enhanced CT scan shows a large, loculated fluid collection (*) within the lesser sac, between the fragments of the pancreatic head and body. (b) Axial contrast-enhanced CT scan obtained after percutaneous drainage shows a catheter (arrowheads) within the pseudocyst. (c) ERCP image shows extravasation of contrast material (arrowheads), thus confirming the transection of the pancreatic duct. Note the drainage catheter within the collection (arrow). A stent was placed in the pancreatic duct during endoscopy (not shown). (d) Axial contrast-enhanced CT scan obtained several weeks after drainage shows resolution of the pseudocyst. Note the stent in the pancreatic duct (arrowhead) and the drainage catheter at the former site of the pseudocyst (arrow). (e) ERCP image obtained the same day as d shows no extravasation of contrast material, thus confirming the integrity of the pancreatic duct.

View larger version (135K): [in a new window]   Figure 3d.  Large pseudocyst due to transection of the pancreatic duct in a 37-year-old man several weeks after blunt trauma. (a) Axial contrast-enhanced CT scan shows a large, loculated fluid collection (*) within the lesser sac, between the fragments of the pancreatic head and body. (b) Axial contrast-enhanced CT scan obtained after percutaneous drainage shows a catheter (arrowheads) within the pseudocyst. (c) ERCP image shows extravasation of contrast material (arrowheads), thus confirming the transection of the pancreatic duct. Note the drainage catheter within the collection (arrow). A stent was placed in the pancreatic duct during endoscopy (not shown). (d) Axial contrast-enhanced CT scan obtained several weeks after drainage shows resolution of the pseudocyst. Note the stent in the pancreatic duct (arrowhead) and the drainage catheter at the former site of the pseudocyst (arrow). (e) ERCP image obtained the same day as d shows no extravasation of contrast material, thus confirming the integrity of the pancreatic duct.

View larger version (94K): [in a new window]   Figure 3e.  Large pseudocyst due to transection of the pancreatic duct in a 37-year-old man several weeks after blunt trauma. (a) Axial contrast-enhanced CT scan shows a large, loculated fluid collection (*) within the lesser sac, between the fragments of the pancreatic head and body. (b) Axial contrast-enhanced CT scan obtained after percutaneous drainage shows a catheter (arrowheads) within the pseudocyst. (c) ERCP image shows extravasation of contrast material (arrowheads), thus confirming the transection of the pancreatic duct. Note the drainage catheter within the collection (arrow). A stent was placed in the pancreatic duct during endoscopy (not shown). (d) Axial contrast-enhanced CT scan obtained several weeks after drainage shows resolution of the pseudocyst. Note the stent in the pancreatic duct (arrowhead) and the drainage catheter at the former site of the pseudocyst (arrow). (e) ERCP image obtained the same day as d shows no extravasation of contrast material, thus confirming the integrity of the pancreatic duct.

View larger version (118K): [in a new window]   Figure 4a.  Transection of the pancreatic neck in a 15-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows a complete fracture of the pancreatic neck with fluid and hemorrhage between the pancreatic fragments; the fluid and hemorrhage track between the pancreas and splenic vein (arrowheads). (b) Axial contrast-enhanced CT scan obtained 5 days later shows expanding fluid collections (*). (c) Endoscopic retrograde pancreatogram shows extravasation of contrast material (arrow), thus confirming the transection of the pancreatic duct. A stent was subsequently placed in the pancreatic duct during endoscopy. (d) Axial contrast-enhanced CT scan obtained 1 month later shows resolution of the fluid collections. Note the indwelling stent (arrows).

View larger version (117K): [in a new window]   Figure 4b.  Transection of the pancreatic neck in a 15-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows a complete fracture of the pancreatic neck with fluid and hemorrhage between the pancreatic fragments; the fluid and hemorrhage track between the pancreas and splenic vein (arrowheads). (b) Axial contrast-enhanced CT scan obtained 5 days later shows expanding fluid collections (*). (c) Endoscopic retrograde pancreatogram shows extravasation of contrast material (arrow), thus confirming the transection of the pancreatic duct. A stent was subsequently placed in the pancreatic duct during endoscopy. (d) Axial contrast-enhanced CT scan obtained 1 month later shows resolution of the fluid collections. Note the indwelling stent (arrows).

View larger version (110K): [in a new window]   Figure 4c.  Transection of the pancreatic neck in a 15-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows a complete fracture of the pancreatic neck with fluid and hemorrhage between the pancreatic fragments; the fluid and hemorrhage track between the pancreas and splenic vein (arrowheads). (b) Axial contrast-enhanced CT scan obtained 5 days later shows expanding fluid collections (*). (c) Endoscopic retrograde pancreatogram shows extravasation of contrast material (arrow), thus confirming the transection of the pancreatic duct. A stent was subsequently placed in the pancreatic duct during endoscopy. (d) Axial contrast-enhanced CT scan obtained 1 month later shows resolution of the fluid collections. Note the indwelling stent (arrows).

View larger version (117K): [in a new window]   Figure 4d.  Transection of the pancreatic neck in a 15-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows a complete fracture of the pancreatic neck with fluid and hemorrhage between the pancreatic fragments; the fluid and hemorrhage track between the pancreas and splenic vein (arrowheads). (b) Axial contrast-enhanced CT scan obtained 5 days later shows expanding fluid collections (*). (c) Endoscopic retrograde pancreatogram shows extravasation of contrast material (arrow), thus confirming the transection of the pancreatic duct. A stent was subsequently placed in the pancreatic duct during endoscopy. (d) Axial contrast-enhanced CT scan obtained 1 month later shows resolution of the fluid collections. Note the indwelling stent (arrows).

View larger version (130K): [in a new window]   Figure 5.  Superficial pancreatic laceration without duct injury in a 17-year-old girl after a motor vehicle collision. Axial contrast-enhanced CT scan shows slight enlargement of the pancreatic tail with a faint laceration line (arrowheads) and surrounding free fluid (*). MR pancreatography performed the same day showed no injury to the pancreatic duct. The patient recovered after conservative treatment.

View larger version (109K): [in a new window]   Figure 6a.  Superficial pancreatic laceration without duct injury in a 19-year-old man after a motor vehicle collision. Axial contrast-enhanced CT scans show a laceration of the distal pancreatic tail (arrows in a, arrow in b). No injury to the pancreatic duct was seen at laparotomy. The patient recovered after conservative treatment.

View larger version (112K): [in a new window]   Figure 6b.  Superficial pancreatic laceration without duct injury in a 19-year-old man after a motor vehicle collision. Axial contrast-enhanced CT scans show a laceration of the distal pancreatic tail (arrows in a, arrow in b). No injury to the pancreatic duct was seen at laparotomy. The patient recovered after conservative treatment.

View larger version (102K): [in a new window]   Figure 7.  Deep pancreatic laceration with duct injury in a 14-year-old girl after a motor vehicle collision. Axial contrast-enhanced CT scan shows a pancreatic laceration that involves more than 50% of the parenchymal thickness (arrow). Note the thickening of the pancreatic tail and the surrounding fluid. Transection of the pancreatic duct was confirmed at surgery, and resection of the pancreatic tail was performed.

View larger version (84K): [in a new window]   Figure 8a.  Disruption of the pancreatic duct with a large fluid collection in a 6-year-old boy after a motor vehicle collision. (a) Axial T2-weighted fat-suppressed MR image shows a fracture of the pancreatic tail (arrow) with associated fluid collections (*). (b) Coronal MR pancreatogram shows communication of the pancreatic duct (arrow) with a large fluid collection (*).

View larger version (82K): [in a new window]   Figure 8b.  Disruption of the pancreatic duct with a large fluid collection in a 6-year-old boy after a motor vehicle collision. (a) Axial T2-weighted fat-suppressed MR image shows a fracture of the pancreatic tail (arrow) with associated fluid collections (*). (b) Coronal MR pancreatogram shows communication of the pancreatic duct (arrow) with a large fluid collection (*).

View larger version (103K): [in a new window]   Figure 9a.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (108K): [in a new window]   Figure 9b.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (119K): [in a new window]   Figure 9c.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (109K): [in a new window]   Figure 9d.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (77K): [in a new window]   Figure 9e.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (85K): [in a new window]   Figure 9f.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (114K): [in a new window]   Figure 9g.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (123K): [in a new window]   Figure 9h.  Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. (a) Axial contrast-enhanced CT scan obtained at presentation shows a fracture of the pancreatic neck (arrow). (b) Axial contrast-enhanced CT scan obtained on day 6 shows expanding fluid collections. (c) Endoscopic retrograde pancreatogram shows transection of the pancreatic duct (arrow) and extravasation of contrast material as large fluid collections (*). However, the segment of the duct upstream of the collections is not demonstrated. (d) Endoscopic retrograde pancreatogram shows a stent in the pancreatic duct (arrow), which was placed during endoscopy. (e, f) Coronal MR images, obtained with the rapid acquisition with relaxation enhancement sequence (e) and with maximum intensity projection reformation of three-dimensional fast spin-echo data (f), show two large fluid collections (*). The segment of the pancreatic duct upstream of the collections is clearly demonstrated (arrow). (g, h) Axial fat-suppressed T1-weighted (g) and T2-weighted (h) MR images obtained 1 month later show resolution of the fluid collections with a residual fracture line (arrows).

View larger version (114K): [in a new window]   Figure 10a.  Laceration of the gallbladder in a 19-year-old man after a motor vehicle collision. Axial contrast-enhanced CT scans show multiple liver lacerations (arrowheads in a) and free intraperitoneal air (*). There is noncontinuous enhancement of the gallbladder wall (arrowheads in b) with surrounding free fluid. Note the duodenal hematoma (arrow in b) and nonenhancement of the right kidney, which were the result of massive crush injury. A gallbladder laceration was confirmed at surgery, and the patient underwent cholecystectomy.

View larger version (121K): [in a new window]   Figure 10b.  Laceration of the gallbladder in a 19-year-old man after a motor vehicle collision. Axial contrast-enhanced CT scans show multiple liver lacerations (arrowheads in a) and free intraperitoneal air (*). There is noncontinuous enhancement of the gallbladder wall (arrowheads in b) with surrounding free fluid. Note the duodenal hematoma (arrow in b) and nonenhancement of the right kidney, which were the result of massive crush injury. A gallbladder laceration was confirmed at surgery, and the patient underwent cholecystectomy.

View larger version (107K): [in a new window]   Figure 11a.  Gallbladder rupture and transection of the cystic artery due to massive blunt trauma in a 6-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows extensive liver lacerations and right adrenal hemorrhage. Note the collection of iodinated contrast material anterior to the portal vein (arrowheads); this finding indicates active hemorrhage due to disruption of the cystic artery. (b) Axial contrast-enhanced CT scan shows noncontinuous enhancement of the gallbladder mucosa (arrowheads). Note the active extravasation of contrast material (arrows). (c) Axial contrast-enhanced CT scan shows dense intraperitoneal fluid (*), which is consistent with hemorrhage. Gallbladder rupture, hemoperitoneum, and transection of the cystic artery were confirmed at laparotomy. The patient underwent cholecystectomy.

View larger version (108K): [in a new window]   Figure 11b.  Gallbladder rupture and transection of the cystic artery due to massive blunt trauma in a 6-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows extensive liver lacerations and right adrenal hemorrhage. Note the collection of iodinated contrast material anterior to the portal vein (arrowheads); this finding indicates active hemorrhage due to disruption of the cystic artery. (b) Axial contrast-enhanced CT scan shows noncontinuous enhancement of the gallbladder mucosa (arrowheads). Note the active extravasation of contrast material (arrows). (c) Axial contrast-enhanced CT scan shows dense intraperitoneal fluid (*), which is consistent with hemorrhage. Gallbladder rupture, hemoperitoneum, and transection of the cystic artery were confirmed at laparotomy. The patient underwent cholecystectomy.

View larger version (110K): [in a new window]   Figure 11c.  Gallbladder rupture and transection of the cystic artery due to massive blunt trauma in a 6-year-old boy after a motor vehicle collision. (a) Axial contrast-enhanced CT scan shows extensive liver lacerations and right adrenal hemorrhage. Note the collection of iodinated contrast material anterior to the portal vein (arrowheads); this finding indicates active hemorrhage due to disruption of the cystic artery. (b) Axial contrast-enhanced CT scan shows noncontinuous enhancement of the gallbladder mucosa (arrowheads). Note the active extravasation of contrast material (arrows). (c) Axial contrast-enhanced CT scan shows dense intraperitoneal fluid (*), which is consistent with hemorrhage. Gallbladder rupture, hemoperitoneum, and transection of the cystic artery were confirmed at laparotomy. The patient underwent cholecystectomy.

View larger version (153K): [in a new window]   Figure 12a.  Intrahepatic bile duct leak in a 20-year-old man after a high-speed motorcycle collision. (a) Axial contrast-enhanced CT scan shows a laceration of the right lobe of the liver (arrowheads) that extends to the hepatic surface. (b) Axial contrast-enhanced CT scan shows a contusion of the right kidney. (c) Axial contrast-enhanced CT scan shows extensive ascites (*). (d, e) ERCP images show disruption of the right hepatic duct and extravasation of contrast material. Note the pooling of contrast material along the right lobe of the liver (arrowheads in e). (f) Hepatobiliary scan obtained 36 minutes after injection of the tracer shows active biliary leakage. Note the activity along the right lobe of the liver (left arrowhead) and within the peritoneum (right arrowhead).

View larger version (147K): [in a new window]   Figure 12b.  Intrahepatic bile duct leak in a 20-year-old man after a high-speed motorcycle collision. (a) Axial contrast-enhanced CT scan shows a laceration of the right lobe of the liver (arrowheads) that extends to the hepatic surface. (b) Axial contrast-enhanced CT scan shows a contusion of the right kidney. (c) Axial contrast-enhanced CT scan shows extensive ascites (*). (d, e) ERCP images show disruption of the right hepatic duct and extravasation of contrast material. Note the pooling of contrast material along the right lobe of the liver (arrowheads in e). (f) Hepatobiliary scan obtained 36 minutes after injection of the tracer shows active biliary leakage. Note the activity along the right lobe of the liver (left arrowhead) and within the peritoneum (right arrowhead).

View larger version (158K): [in a new window]   Figure 12c.  Intrahepatic bile duct leak in a 20-year-old man after a high-speed motorcycle collision. (a) Axial contrast-enhanced CT scan shows a laceration of the right lobe of the liver (arrowheads) that extends to the hepatic surface. (b) Axial contrast-enhanced CT scan shows a contusion of the right kidney. (c) Axial contrast-enhanced CT scan shows extensive ascites (*). (d, e) ERCP images show disruption of the right hepatic duct and extravasation of contrast material. Note the pooling of contrast material along the right lobe of the liver (arrowheads in e). (f) Hepatobiliary scan obtained 36 minutes after injection of the tracer shows active biliary leakage. Note the activity along the right lobe of the liver (left arrowhead) and within the peritoneum (right arrowhead).

View larger version (128K): [in a new window]   Figure 12d.  Intrahepatic bile duct leak in a 20-year-old man after a high-speed motorcycle collision. (a) Axial contrast-enhanced CT scan shows a laceration of the right lobe of the liver (arrowheads) that extends to the hepatic surface. (b) Axial contrast-enhanced CT scan shows a contusion of the right kidney. (c) Axial contrast-enhanced CT scan shows extensive ascites (*). (d, e) ERCP images show disruption of the right hepatic duct and extravasation of contrast material. Note the pooling of contrast material along the right lobe of the liver (arrowheads in e). (f) Hepatobiliary scan obtained 36 minutes after injection of the tracer shows active biliary leakage. Note the activity along the right lobe of the liver (left arrowhead) and within the peritoneum (right arrowhead).

View larger version (102K): [in a new window]   Figure 12e.  Intrahepatic bile duct leak in a 20-year-old man after a high-speed motorcycle collision. (a) Axial contrast-enhanced CT scan shows a laceration of the right lobe of the liver (arrowheads) that extends to the hepatic surface. (b) Axial contrast-enhanced CT scan shows a contusion of the right kidney. (c) Axial contrast-enhanced CT scan shows extensive ascites (*). (d, e) ERCP images show disruption of the right hepatic duct and extravasation of contrast material. Note the pooling of contrast material along the right lobe of the liver (arrowheads in e). (f) Hepatobiliary scan obtained 36 minutes after injection of the tracer shows active biliary leakage. Note the activity along the right lobe of the liver (left arrowhead) and within the peritoneum (right arrowhead).

View larger version (84K): [in a new window]   Figure 12f.  Intrahepatic bile duct leak in a 20-year-old man after a high-speed motorcycle collision. (a) Axial contrast-enhanced CT scan shows a laceration of the right lobe of the liver (arrowheads) that extends to the hepatic surface. (b) Axial contrast-enhanced CT scan shows a contusion of the right kidney. (c) Axial contrast-enhanced CT scan shows extensive ascites (*). (d, e) ERCP images show disruption of the right hepatic duct and extravasation of contrast material. Note the pooling of contrast material along the right lobe of the liver (arrowheads in e). (f) Hepatobiliary scan obtained 36 minutes after injection of the tracer shows active biliary leakage. Note the activity along the right lobe of the liver (left arrowhead) and within the peritoneum (right arrowhead).