Pancreatitis associated with remote traumatic brain injury in children

Relationship between increases in pancreatic enzymes and cerebral events in children after traumatic brain injury

OBJECTIVE

To describe the risk factors of early and delayed increases in pancreatic enzymes (PE) in children after severe traumatic brain injury (TBI) and to determine if cerebral events (such as intracranial hemorrhage or intracranial hypertension) are associated with increases in PE.

DESIGN AND SETTINGS

Retrospective analysis of prospectively collected Pediatric Neurotrauma Registry for children with severe TBI (GCS ≤ 8). We assessed the association of clinical characteristics with the development of increases in PE using regression analyses.

PATIENTS

Fifty-one children with severe TBI were classified into three groups [normal PE; early PE (PE increases within first 24 h); delayed PE (PE increases after 24 h)].

MEASUREMENTS AND MAIN RESULTS

Increases in PE were observed in 29/51 children [57% total; n = 9 (18%) early; n = 20 (39%) delayed]. Multisystem trauma was more prevalent in patients with early increases in PE compared to those without increases in PE (70 vs. 30%, RR = 2.8, 95% CI 1.1-7) but not different between delayed PE and normal PE groups. In the bivariate analyses, increasing age (odds ratios, [95% CI]; 1.2, [1.05-1.4]), intracranial hypertension (14.6, [2.6-80.5]), intracranial hemorrhage (6.2, [1.15-33.7]), receipt of pentobarbital (9.3, [2.1-39.9]), mannitol (13.2, [2.7-62.2]), and vasoactive medications (6.9, [1.5-31.3]) were associated with the development of delayed increases in PE, whereas sex, initial Glasgow Coma Scale, severity of injury (PRISM, Injury Severity Score), therapeutic hypothermia, morphine and furosemide were not associated. Both intracranial hypertension and intracranial hemorrhage independently predicted the development of increases in PE (14.6, [2.6-80.5], and 9.1, [1.31-63.3], respectively).

CONCLUSIONS

Increases in PE, often used as the only measures of pancreatitis in children with other severe injuries, are common in children after severe TBI and delayed presentation appears related to intracranial events. This suggests a possible interaction between the brain and the gastrointestinal system, implying that disturbances in cerebral hemodynamics may lead to pancreatic dysfunction.

Urinoma: an unusual case of emesis in a brain-injured child

The evaluation of acute emesis in a multiple-trauma paediatric patient with severe traumatic brain injury can present a difficult but not unusual problem in the rehabilitation unit. The differential diagnosis will be discussed in a paediatric case in which emesis was related to a urinoma, secondary to ureteropelvic disruption, compressing the duodenum. We present a case of a 6-year-old Caucasian girl with severe brain injury who developed emesis while in rehabilitation. An X-ray of the abdomen revealed a shadow over the right psoas. Subsequently mild compression of the duodenum was diagnosed by computerized tomography, and ultrasound demonstrated a large fluid collection inferior to the right kidney. A large volume of urine was drained and a catheter placed. Pyelogram revealed apparent disruption of the right ureteropelvic junction, which was confirmed intraoperatively. The kidney was removed secondary to severe parenchymal abnormalities. The emesis subsequently resolved. Differential diagnosis of acute onset of emesis in the paediatric brain-injured patient should include a careful search for underlying previously unrecognized problems.