Pancreatic trauma

Key points

Epidemiology and Mechanism of Injury

• Pancreatic trauma accounts for <10% of abdominal injuries in children

• Most common cause: Blunt trauma (e.g., handlebar injuries, falls, MVAs)

• Penetrating trauma is rare

• Diagnostic delay is common due to nonspecific symptoms and retroperitoneal position

Imaging

American association for the Surgery of Trauma (AAST) Pancreas Injury Scale

Grade I: Haematoma with minor contusion or superficial laceration without duct injury

Grade II: Major contusion or laceration without duct injury

Grade III: Distal transection or deep parenchymal injury with duct injury

Grade IV: Proximal transection or deep parenchymal injury involving the ampulla and/or intrapancreatic common bile duct

Grade V: Massive disruption of the pancreatic head ("shattered pancreas")

Management principles

Non-Operative Management (Grades I–II)

• Indications: Stable patients, no ductal injury

• Components:

  • NG tube for decompression if vomiting

  • IV fluids and analgesia

  • NJ/PN if ileus persists

• Monitoring for complications: pseudocyst, pancreatitis

Grade 3 injuries

No need for MRCP/ERCP to investigate if CT confirmed ductal injury

Controversial as to whether conservative management or distal pancreatectomy is better

• Lengths of stay (LOS) are generally similar between non-operative management (NOM) and operative management (OM) for pancreatic injuries

• NOM is associated with higher rates of certain complications, such as pseudocysts

• OM is preferred for more severe pancreatic injuries

• Success rates for NOM are higher in lower-grade injuries

Injuries more than 48 hours old are associated with significant oedema and make surgery difficult

Some centres prefer distal pancreatectomy + drain for injuries <48h old, and conservative management for injuries >48h old

If >50% of the pancreas is resected, patient will have impaired glucose tolerance

Grade 4/5 injuries

Manage conservatively, can use stent +/- drain

If duodenum injured - may need Whipples procedure

Fistula is major post op complication

Follow up grade 3+ injuries for year for pancreatic insufficiency

Non-operative management principles

Feed after 1-2 days after resolution of epigastric tenderness

No evidence for prophylactic octreotide

Follow up imaging at 4-6 weeks for pseudocyst

MRCP at 6 weeks for duct continuity for severe injuries

Role of Endoscopy and Interventional Radiology

ERCP (Endoscopic Retrograde Cholangiopancreatography)

• Gold standard for evaluating pancreatic duct injuries

• Differentiates contusion vs. transection

• Enables stenting across ductal injuries

Indications for ERCP and Stenting

• Partial or complete ductal transection (AAST III–IV)

• Stable patients

• Prevents or manages pseudocyst formation

• Increasingly used in paediatric centres

Procedure Overview

• Performed under general anaesthesia

• Side-viewing duodenoscope passed to second part of duodenum

• Cannulation of pancreatic duct → contrast injection

• Guidewire and stent placed across injury

• Stents removed after 4–6 weeks

Limitations in Children

• Small ductal size complicates cannulation

• Limited access to paediatric ERCP expertise

• Not suitable for unstable patients or complete transections

Complications

• ERCP-related: Pancreatitis, infection, bleeding

• Stent-related: Migration, occlusion, need for repeat procedures

Special Scenario - Post-Traumatic Pseudocyst

Definition

• A pancreatic fluid collection rich in enzymes, surrounded by fibrous (non-epithelial) wall

• Develops 2–6 weeks post-injury

Clinical Features

• Abdominal pain, mass

• Early satiety, vomiting

• Gastric outlet obstruction symptoms

Diagnosis

• Labs: Amylase/lipase, CRP, WBC

• Imaging:

  • Ultrasound: Simple/complex cyst

  • CT: Wall thickness, location, size

  • MRCP: Ductal anatomy

Management of Pseudocysts

1. Conservative Management

• For asymptomatic cysts <6 cm, <6 weeks old

• Serial imaging every 2–4 weeks

• Nutritional support

2. Interventional Management

Indications:

• Size >6 cm

• Persistence >6 weeks

• Symptoms or infection

• Ductal communication

Techniques

• Endoscopic drainage (cystogastrostomy):

  • Indicated for mature cysts

  • Transgastric or transduodenal approach

  • Internal stent placement (plastic/metal - e.g. Hot AXIOS)

• Surgical drainage:

  • Reserved for failed non-invasive methods

  • Cystogastrostomy, Cystojejunostomy, Cystoduodenostomy

Outcomes and Prognosis

• Early recognition of ductal injury is key

• ERCP and stenting have significantly reduced morbidity

• Most children recover fully with appropriate care

• Delayed complications like pseudocysts are manageable with evolving techniques

Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. October 2025

Page edited by Mrs Charnjit Seehra BSc October 2025

References

Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum.

Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG.

J Trauma. 1990 Nov;30(11):1427-9.

www.aast.org

List of 32 Tables

Naik-Mathuria, Bindi, and Nikhil R Shah. "Pancreatic Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829089/all/Pancreatic_Trauma.