Pancreatic injury in children is uncommon. Evidence of pancreatic injury
was present in only 2% of all pediatric trauma referred to hospital. Pancreatic duct
injuries are rare, occurring in only 0.1% to 0.4% of pediatric trauma victims. (3)
As in adults, the severity of pancreatic injury and particularly the presence of
pancreatic duct injury predicts morbidity and mortality. (65)
Most injuries occur in boys and are related to bicycle handlebars. The
mechanism of trauma is usually by direct compression of the pancreas against the
underlying lumbar vertebrae, thus explaining the predilection for injury at the
pancreatic neck. (66)
Diagnosis remains difficult despite advances in imaging techniques. Initial
symptoms, even in children with severe injuries, are often minimal. The most
common signs are epigastric abdominal pain, and tenderness which is present, for
the most part, immediately after the injury. (68)
It has been reported that serum amylase levels do not correlate with the
severity of injury. (69)
The initial plasma amylase level has a variable sensitivity (50–90%) and specificity
in the diagnosis of pancreatic trauma in children but serial amylase measurements
are useful in detecting pancreatic complications. (72)
Ultrasonography reliably identifies enlargement of the pancreas and
peripancreatic fluid collection but fails to determine the integrity of the pancreatic
duct. (110)
A contrast-enhanced CT scan provides the best assessment of abdominal
injuries after major trauma, but injury to the main pancreatic duct may be
Summary & Conclusion
83
overlooked. In a series of 16 children from California, pancreatic duct injury was
detected on the admission CT scan in 11 cases, a diagnostic accuracy of 70%. (70)
Pancreatic duct injuries are less likely to be missed if thin CT slices are
acquired and if the scan is performed 12 to 24 hours after injury (when edema
accentuates the transection line). (70)
ERCP has become an accepted diagnostic method to evaluate for pancreatic
ductal injury Additionally, ERCP may also develop into a valuable option for
therapeutic intervention, including stent placement, in proximal ductal injuries and
should be considered in those patients. (77)
The management of pancreatic injuries should be individualized depending
on the site of injury, timing of referral, presence of associated injuries, and
institutional expertise and logistics. (9)
Children who have suffered pancreatic injury (but without ductal disruption)
do not appear to suffer increased morbidity after conservative management; these
data suggest that patients with ductal disruption may benefit from early operative
intervention. (105)
Conservative management of pancreatic trauma in the absence of a ductal
injury (grade I and II) is widely accepted and practiced as the majorities are
contusions that usually resolve spontaneously after 4 to 10 days of conservative
treatment. (125)
Children referred early with clearly defined grade III injuries probably
benefit from an early spleen-sparing distal pancreatectomy. Those with grade IV
injuries frequently require laparotomy when Roux-en- Y drainage of the fracture
site is a useful technique. (143) |
