Pancreatic injury is often the result of a direct blow to the upper abdomen of a child. The classic “handle bar” injury often leaves a circular mark directly over the expected location of the pancreas. Pancreatic injury is often suggested by elevated blood tests (lipase and amylase levels) and/or a CT scan of the abdomen.
True pancreatic duct injuries are rare in pediatric blunt trauma. CT scan will often over-diagnose pancreatic transection. Duct injuries may also be completely missed on initial CT scan, especially if done shortly after the injury took place.
Main pancreatic duct transection is determined by ERCP or MRCP in a patient with a history, physical exam and labs suggestive of pancreatic injury.
In pediatric trauma, AAST Grading guides management.
from Ernest E. Moore, MD, Thomas H. Cogbill, MD, Mark Malangoni, MD, Gregory J. Jurkovich, MD, and Howard R. Champion, MD. Scaling system for organ specific injuries. EAST Guidelines.
Treatment decision is algorithm-based, and ERCP or MRCP mandatory. The presence of pancreatic duct disruption accounts for most of the complications. Identification of this injury is paramount.
Acute ERCP is safe and accurate in children, and may allow for definitive treatment of ductal injury by stenting in selected patients. If a facility cannot perform MRCP or ERCP in a pediatric patient, transfer to an appropriate pediatric trauma facility should be considered.
From Duchesne JC, Schmieg R, Islam S, Olivier J, McSwain N. J Trauma. 2008 Jul;65(1):49-53.
Selective nonoperative management of low-grade blunt pancreatic injury: are we there yet?
Grade I and II pancreatic injury: ERCP to grade injury, observation, serial exams, fluid management and followup scans as indicated.
Grade III = disruption of distal duct — Consider Distal pancreatectomy.*
Grade IV proximal duct injury: Options include : External drainage alone or Roux en Y drainage. Most authors advocate individualizing surgical treatment
Grade V massive disruption of head: Care must be individualized. Consider Damage control laparotomy, wide drainage and staged Whipple.
*Grade III Pancreatic injuries have been successfully managed nonoperatively, allowing for the formation and uneventful drainage of a pseudocyst. This has a unique set of risks and complications and should only be done in centers with experience with this management technique. The main limitation of these studies have often been including patient without confirmed ductal injuries in this group. Many reported cases of failure of conservative management.
Eastern Trauma guidelines pdf for management of pancreatic injury can be found at EAST.
AAST Organ Injury
References
Canty TG Sr, Weinman D. J Trauma. 2001 Jun;50(6):1001-7. Management of major pancreatic duct injuries in children.
Stringer MD. Br J Surg. 2005 Apr;92(4):467-70. Pancreatic trauma in children.
Thomas H, Madanur M, Bartlett A, Marangoni G, Heaton N, Rela M. Pancreas. 2009 Mar;38(2):113-6. Pancreatic trauma–12-year experience from a tertiary center.
Ernest E. Moore, MD, Thomas H. Cogbill, MD, Mark Malangoni, MD, Gregory J. Jurkovich, MD, and Howard R. Champion, MD. Scaling system for organ specific injuries. EAST Guidelines.
Duchesne JC, Schmieg R, Islam S, Olivier J, McSwain N. J Trauma. 2008 Jul;65(1):49-53.
