[size=20px]A 14 year old boy fell from his bicycle four days ago. He now presents to the emergency room with tachycardia, upper abdominal pain and vomiting. An abdominal computerized tomography scan demonstrates diffuse inflammation in the mid body of the pancreas consistent with a pancreatic contusion with no evidence of ductal injury or pancreatic laceration. The white blood cell count is 16,000/uL, amylase 2450 U/L and lipase 1860 U/L. The remainder of his trauma evaluation reveals no additional injuries. The most appropriate next step in management is:

 

A Distal pancreatectomy with splenic preservation

 

B Roux-en-Y pancreaticojejunostomy

 

C Urgent ERCP with stent placement

 

D Continue fluid resuscitation, NPO

 

E Pyloric exclusion[/size]

D

D

correct answer

D Continue fluid resuscitation, NPO

 

This patient presents with an isolated Grade II pancreatic injury after blunt trauma. Computed tomography (CT) scan is the diagnostic modality of choice in hemodynamically stable blunt abdominal trauma patients to diagnose pancreatic injury. The sensitivities for detecting pancreatic injury are highly variable ranging from 47% to 79%, with newer-generation scanners being more sensitive. Pediatric pancreatic ductal injuries are relatively uncommon following blunt trauma. The optimal management of pancreatic injuries in children remains uncertain and authors fall out on both sides of the argument whether an operative or nonoperative approach. Despite the disagreement over the optimal management of a child who presents early after injury, there is less disagreement concerning the management of children with delayed presentations. The Eastern Association for the Society of Trauma recommends non-operative management for adults who present with Grade I or II pancreatic injuries. Smaller series have evaluated the role of non-operative management in the pediatric population. Given the clinical presentation, pancreatic resection or diversion is not indicated. Pyloric exclusion should be reserved for a complex injury to the pancreatic head that involves the duodenum. As the CT scan showed no evidence of ductal injury, at this point an ERCP is not indicated. It is not uncommon for patients to develop an organized fluid collection following nonoperative management which may prompt evaluation with ERCP at a later date.