CT and MRI findings in pancreatic trauma in children and correlation with outcome

Abstract

Background There are limited published data on pancreatic trauma imaging in children. Objective To present our experience using computed tomography (CT) and magnetic resonance (MR) imaging of pancreatic trauma in children and to correlate the imaging grade of pancreatic injury with management and outcome. Materials and methods A retrospective cohort study of children with pancreatic injury presenting between Jan. 1, 2000, and Dec. 31, 2016, was performed. Patient charts were reviewed to note demographics, the mechanism of injury, associated abdominal injuries, management and outcome. All imaging was rereviewed by two radiologists blinded to clinical and laboratory information, and pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST). Results Of 3,265 patients presented as trauma team activations during the study period, only 28 (0.86%) children (19 boys, 9 girls; mean age: 7.14 years; age range: 1-15 years) had pancreatic injury. Of the available 27 CTs of the abdomen, 26 were performed on the day of trauma. Associated injuries were seen in 25/27 children, most frequently in the liver and lung, 16 (59.2%) each. There were 5 (19%) Grade I, 9 (33%) Grade II, 8 (30%) Grade III and 3 (11%) Grade IV. No patients had Grade V injury. No pancreatic parenchymal injury was identified in 2 (7%) patients with isolated fluid around the pancreas and mesentery. The pancreatic duct was visible in all 10 children (days: 0-330, median days: 41 post-trauma) who had MRI. Eight of these children, who had Grade III/IV injuries on CT and confirmed pancreatic duct injury on endoscopic retrograde cholangiopancreatography (ERCP) or surgery, showed either signal intensity difference in pancreatic parenchyma and/or caliber difference in the pancreatic duct proximal and distal to the injury site. Two patients died because of multiorgan injuries, 9 patients (mainly with Grade III and IV injuries) underwent surgery and/or ERCP, and 16 patients were managed conservatively. AAST grading of pancreatic injury on CT correlated with type of management (P=0.0001) with most of the Grade III and IV injuries treated with intervention and/or surgery while all of the Grade I and II injuries were treated conservatively. Conclusion Pancreatic injury is rare in children but often associated with other organ injuries most frequently involving the liver and lung. CT grading of injury correlates with management and guides intervention and/or surgery versus conservative treatment. MRI is useful for assessing pancreatic duct injury by demonstrating the pancreatic duct directly and/or secondary changes like signal intensity difference in pancreatic parenchyma and caliber difference in the pancreatic duct.

Complete Traumatic Rupture of the Pancreas by a Horse Saddle: A Case Report

“…Additionally, in pediatric patients, its diagnostic yield has been shown to be low, making MRCP the preferred imaging modality in these cases. This image study is useful for assessing PD injuries by demonstrating the PD directly or by showing secondary changes, such as signal intensity difference in pancreatic parenchyma and caliber difference in the PD, even when the rupture is not as clear as in this case [ 8 ]. Correct evaluation of the PD involvement and anatomical correction is critical to determine its classification according to the AAST (Figures 4A - 4E ) and its possible therapeutic approach, either conservative or surgical.…”

“…Damage control surgery is the best alternative for severe life-threatening cases where severe acute inflammation makes safe resection impossible, in this case endoscopic stent placement is also recommended. Nevertheless, pancreatic resection surgery has been proven to be one of the best surgical procedures as it has been associated with less need for reoperation, so it should be considered over drainage [ 8 ]. When speaking about pancreatic resection, a distal pancreatectomy with splenectomy is one of the most commonly performed procedures for distal injuries, but proximal injuries require a stage-specific approach usually executed by an HPB surgeon [ 10 ].…”

Isolated pancreatic injury following blunt trauma in a seven-year-old girl: A case report

“…CT grading of injury correlates with and guides the management approach, and CECT abdomen is the preferred investigation for diagnosis. Magnetic resonance cholangiopancreatography (MRCP) helps assess pancreatic duct injury by demonstrating the pancreatic duct directly and/or secondary changes like signal intensity difference in pancreatic parenchyma and caliber difference in the pancreatic duct [ 12 ].…”

Cases of pediatric intra-abdominal solid organ injury induced by blunt trauma experienced over a 15-year period at two centers in Japan

“… 4 Magnetic resonance cholangiopancreatography is also a non-invasive and useful modality to work up pancreatic injury if patients are stable. 5 While it is widely accepted that most hepatic or splenic injuries can be managed non-operatively regardless of grade, management of pediatric pancreatic injury remains controversial. In any case, treatment at a specialized facility is almost always considered to be highly desirable.…”

“…4 Magnetic resonance cholangiopancreatography is also a non-invasive and useful modality to work up pancreatic injury if patients are stable. 5 While it is widely accepted that most hepatic or splenic injuries can be managed non-operatively regardless of grade, management of pediatric pancreatic injury remains controversial. In any case, WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ In the treatment of blunt abdominal trauma in children, it is necessary to accurately diagnose the injured organ and the severity of the injury, and quickly make a decision on whether to choose conservative treatment, laparotomy, or non-laparotomy treatment, including interventional radiology.…”