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A 7 year old boy presented to the accident and emergency (A&E) department with an abdominal injury after a fall onto a bedpost while playing. He initially felt “dizzy” and went to bed but was brought to A&E six hours after the fall complaining of abdominal pain. On initial assessment he was pale and clammy with a capillary refill time of four seconds. Heart rate was 110/min but blood pressure was normal. Abdominal examination revealed upper abdominal tenderness with slight discolouration in the left upper quadrant. After fluid resuscitation and analgesia an ultrasound examination suggested free blood in the peritoneal cavity. Serum amylase on admission was 71 IU/l. A subsequent urgent computed tomogram showed complete transection through the body of the pancreas (fig 1).
Treatment was conservative with analgesia and total parenteral nutrition. Nasojejunal feeding was gradually introduced. Twenty seven days after admission the patient required percutaneous drainage of a pancreatic pseudocyst. Recovery thereafter was uneventful and he was discharged home on a normal diet 50 days after admission. He remains well nine months later.
Pancreatic injury occurs in up to 10% of paediatric blunt abdominal trauma. Handlebar injuries are a common mechanism and result in a pattern of isolated pancreatic injury, often complicated by pseudocyst development.1 Delayed diagnosis is the greatest determinant of morbidity and a high index of suspicion is required for optimal outcome. Complete transection is relatively rare and although the diagnostic accuracy of computed tomography has been questioned in recent years, computed tomography still gives the best opportunity for immediate diagnosis.2 Serum amylase is not a reliable marker of pancreatic injury as it is often normal in the first few hours after injury, becoming raised in 80% of cases. Non-operative management of pancreatic contusion and transection diagnosed radiologically is effective and safe. Pseudocysts may also be treated conservatively, but if large or symptomatic may need percutaneous drainage.3