Pancreatic injury in children: a case report and review of the literature

Abstract

BackgroundTrauma is the main cause of morbidity and mortality in the pediatric population. Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury, although uncommon (2 to 9%), is the fourth most common solid organ injury. Unlike other solid organ injuries, pancreatic trauma may be subtle and difficult to diagnose. Computed tomography currently is the imaging modality of choice.As the incidence of pancreatic injury in children sustaining blunt abdominal trauma is low, management remains a challenge.Case presentationWe present a 7-year-old Bahraini boy who sustained blunt trauma to his abdomen. He presented with abdominal pain and vomiting. His examination revealed abdominal distension and an epigastric bruise. Contrast-enhanced computed tomography reported grade III liver injury, grade I bilateral renal injury, a suspicion of splenic injury, and a grade III to IV pancreatic injury. He was admitted to Pediatric Intensive Care Unit and was treated conservatively. Because he was stable, he was discharged to the surgical ward at day 3. At day 18 he developed a pancreatic pseudocyst that was aspirated and recurred at day 25 when a pigtail catheter was inserted. He was kept on total parenteral nutrition through a peripherally inserted central catheter. The pigtail catheter was removed on day 36 and a low fat diet was started by day 44. He was discharged home at day 55 in good health. Out-patient follow-up and serial abdominal ultrasound showed resolution of the cyst and normalization of blood tests.ConclusionNon-operative management of pancreatic injury is effective and safe in hemodynamically stable patients with no other indication for surgery.

Nonresection management of the pancreas for grade III and IV blunt pancreatic injuries in children: a single center’s experience

“…It is generally accepted in adults that grade I-II pancreatic injuries can be treated nonsurgically and that grade III or higher should receive resection management of the pancreas [ 14 ]. However, the optimal treatment of high-grade blunt pancreatic injuries is still controversial for pediatric surgeons worldwide because splenectomy is sometimes performed simultaneously during distal pancreatic resection, which does not meet parents’ expectations [ 13 , 15 ]. Therefore, all patients with blunt pancreatic injury at our center received initial conservative treatments in the last 10 years, except for children with gastrointestinal injury or continued hemorrhagic shock.…”

“…The abdominal US is the primary examination method for patients with abdominal trauma but is generally insensitive to pancreatic injury diagnosis [ 15 , 16 ]. All patients in our study underwent the abdominal US after injury, but the positive rate of initial US was 65.0%, which was related to the operator’s diagnostic level.…”

“…The main reasons were as follows: first, the initial CT may not be able to reveal direct signs such as injury of the main pancreatic duct; second, combined pancreatic injury can interfere with an accurate diagnosis, which was confirmed by our studies (28.5%). Only when secondary findings such as peripancreatic effusion appeared with disease progression were the diagnosis became easier and more accurate [ 15 , 19 ]. Therefore, MRI is equally necessary for children with pancreatic injuries, especially in older children under stable conditions [ 20 , 21 ].…”

Pediatric ultrasonography of the pancreas: normal and abnormal findings

“…The mechanism of injury is attributed to the compression of the pancreas against the rigid spinal column or by discrete intrusion forces. Young children with flatter diaphragms, thinner abdominal walls, and higher costal margins sustain pancreatic injuries from blows to the abdomen more than adults particularly in accidents with bicycles (handlebar injury) or in abuse and vehicle trauma (seat belt injury) [2,26].…”

“…19,20) [3]. This capacity of US is important in the diagnosis and treatment of pancreatic trauma but US cannot sufficiently display the location and severity of pancreatic lesions [26]. However, CEUS (contrast enhanced US), as off label use in pediatric population, is significantly accurate in identifying post-traumatic injury to abdominal solid organs as well as pancreatic gland, reaching a sensitivity almost equal to that of CT [29,30].…”