Blunt Abdominal Trauma in the Pediatric Patient

What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children?

BACKGROUND AND STUDY AIMS

Trauma is one of the most common causes of morbidity and mortality in the pediatric population. The diagnosis of pancreatic injury is based on clinical presentation, laboratory and imaging findings, and endoscopic methods. CT scanning is considered the gold standard for diagnosing pancreatic trauma in children.

PATIENTS AND METHODS

This retrospective study evaluates data from 25 pediatric patients admitted to the University Hospital Motol, Prague, with blunt pancreatic trauma between January 1999 and June 2013.

RESULTS

The exact grade of injury was determined by CT scans in 11 patients (47.8%). All 25 children underwent endoscopic retrograde cholangiopancreatography (ERCP). Distal pancreatic duct injury (grade III) was found in 13 patients (52%). Proximal pancreatic duct injury (grade IV) was found in four patients (16 %). Major contusion without duct injury (grade IIB) was found in six patients (24%). One patient experienced duodeno-gastric abruption not diagnosed on the CT scan. The diagnosis was made endoscopically during ERCP. Grade IIB pancreatic injury was found in this patient. One patient (4%) with pancreatic pseudocyst had a major contusion of pancreas without duct injury (grade IIA). Four patients (16%) with grade IIB, III and IV pancreatic injury were treated exclusively and nonoperatively with a pancreatic stent insertion and somatostatine. Two patients (8%) with a grade IIB injury were treated conservatively only with somatostatine without drainage. Eighteen (72 %) children underwent surgical intervention within 24 h after ERCP.

CONCLUSION

ERCP is helpful when there is suspicion of pancreatic duct injury in order to exclude ductal leakage and the possibility of therapeutic intervention. ERCP can speed up diagnosis of higher grade of pancreatic injuries.

Grade III Liver Laceration in a Female Volleyball Player

A 20-year-old female collegiate volleyball athlete (body mass, 74.8 kg; height, 177.8 cm), with no previous history of abdominal injury, dove for a ball during a match and was struck in the anterolateral abdominal region by a teammate’s knee. She experienced a solar plexus spasm, shortness of breath, and nausea. On-site evaluation revealed sharp pain in the right upper quadrant and epigastric area, pallor, continued nausea, and excessive sweating. Upon arrival to the emergency department, an abdominal/pelvic computed tomography (CT) scan with intravenous contrast showed a small amount of fluid along the posteromedial surface of the liver indicating a subcapsular hematoma. A trace amount of free fluid in the right paracolic gutter and pelvis was also noted, suggesting a hemoperitoneum. The athlete was diagnosed with a grade III laceration (> 3 cm parenchymal depth) on the right lobe of the liver. She was hemodynamically stable and vital sign values were normal ~2.5 hours postinjury (blood pressure, 118/76 mm Hg; heart rate, 68 beats per minute; respiratory rate, 16 breaths per minute; tympanic temperature, 36.3°C). The athlete was admitted into the intensive care unit for observation, and the attending physician decided on a conservative, nonoperative approach to treatment. Forty-eight hours postinjury, a second abdominal/pelvic CT scan was ordered and revealed no increased bleeding or extensive damage to the liver. Two days later, after being discharged from the hospital, she was prohibited from practicing until a third abdominal/pelvic CT scan was performed and showed no residual injury to the liver (5 weeks postinjury). The athlete returned to play 6 weeks postinjury without complications; however, she continued performing rehabilitation focusing on cardiorespiratory endurance.

Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?

BACKGROUND

Computerized tomography (CT) is considered as the imaging study of choice for blunt abdominal trauma in children. Nevertheless, recent investigations clearly indicate an increased risk of cancer in children exposed to radiation during abdominal spiral CT. Therefore, alternative strategies should be used for the diagnosis and surgical decision making in blunt abdominal trauma in children.

METHODS

Retrospective analysis included all children with intraabdominal organ rupture after blunt abdominal trauma. Patients were diagnosed by a standardized emergency protocol that included primary clinical assessment and repeated ultrasound but not routine CT. Efficacy of abdominal ultrasound was evaluated in regard to safe diagnosis and appropriate surgical decision making.

RESULTS

The study included 35 children with intraabdominal organ rupture diagnosed by ultrasound. One fifth (7/35) of the patients were polytraumatized, whereas 28 of 35 had an isolated blunt abdominal trauma. All patients underwent immediate ultrasound scanning of the abdomen and retroperitoneal space. Two patients were immediately operated because of hemodynamically instability. Four of 7 polytraumatized patients and 7 of 28 patients with isolated blunt abdominal trauma were additionally diagnosed by spiral CT. Only 1 patient underwent subsequent surgery because of the findings in the CT. Ultrasound was effective in more than 97% (34/35) of the patients for diagnosis and appropriate surgical decision making.

CONCLUSION

Ultrasound combined with clinical assessment presents an effective method for safe diagnosis and appropriate surgical decision making in pediatric blunt abdominal trauma. Selected cases with polytrauma and/or unequivocal findings in the ultrasound should undergo abdominal CT. Patients requiring abdominal CT should have an anticipated benefit that exceeds the radiation risk. The importance of repeated clinical assessment cannot be overstated.