Pancreatic Laceration in a Pediatric Patient: An Unexpected Diagnosis

Abstract

Pediatric pancreatic injuries are rare. We present an atypical case that occurred in a 4-year-old male. The child presented with a twenty-four-hour history of vomiting that had progressed to right lower quadrant abdominal pain on examination in the emergency department. The initial differential was gastroenteritis versus appendicitis. An abnormality on the ultrasonography and an elevated lipase level eventually led to an MRI showing a complete transection through the posterior margin of the pancreas. The patient was admitted to pediatric surgery and underwent a successful distal pancreatectomy with preservation of the spleen. On further inquiry specific to trauma, the child disclosed that his older brother had punched him in his abdomen the night before. The child's parents were separated due to intimate partner violence, and this older sibling recently had been very stressed. The sibling was referred for mental health evaluation and counseling, and the case reported to the county children and youth investigative services system. A low threshold for considering trauma and child abuse in the pediatric population is recommended when significant intra-abdominal injury is diagnosed.

The Pancreas in Child Abuse

“…Pancreatic injuries are seen fairly uncommonly in pediatric autopsies. Since the pancreas has a retroperitoneal location, it is often spared during more minor abdominal trauma events (1). Injuries of the gland are rare, accounting for less than 2% of all abdominal injuries in children (2).…”

“…A less muscular and thinner anterior abdominal wall and less intraabdominal adipose tissue provide less cushioning and resistance to a blow to the abdomen, compared to adults. In a direct, deep impact of the pediatric abdomen, the pancreas is compressed between the force on the abdominal wall and the unyielding spinal column, resulting in laceration, transection, and/or hemorrhage (Figure 1) (1, 3). Aside from an inflicted blow to the abdomen, other etiologies of such direct, deep impacts with significant pancreatic injury are most commonly motor vehicle collisions and bicycle handlebar injuries (1, 4 –6).…”

“…In a direct, deep impact of the pediatric abdomen, the pancreas is compressed between the force on the abdominal wall and the unyielding spinal column, resulting in laceration, transection, and/or hemorrhage (Figure 1) (1, 3). Aside from an inflicted blow to the abdomen, other etiologies of such direct, deep impacts with significant pancreatic injury are most commonly motor vehicle collisions and bicycle handlebar injuries (1, 4 –6). A retrospective study by Jacombs et al of all children under 16 years of age with pancreatic trauma admitted to a major children’s hospital in New South Wales demonstrated that the majority of blunt force pancreatic injuries were due to motor vehicle collisions, with the majority of injuries being contusions or lacerations without duct injury or tissue loss (7).…”

“…with significant pancreatic injury are most commonly motor vehicle collisions and bicycle handlebar injuries (1,(4)(5)(6). A retrospective study by Jacombs et al of all children under 16 years of age with pancreatic trauma admitted to a major children's hospital in New South Wales demonstrated that the majority of blunt force pancreatic injuries were due to motor vehicle collisions, with the majority of injuries being contusions or lacerations without duct injury or tissue loss (7).…”

Pediatric Pancreatitis: Not a Rare Entity

“…Pediatric pancreatic injuries are uncommon and can be mostly ascribed to vehicle accidents. Anyway because of its retroperitoneal location pancreas is preserved in case of minor abdominal traumas and a pancreatic transection can occur clinically silent [6].…”