Isolated and Combined Duodenal and Pancreatic Injuries: A Review and Update

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Gastrointestinal Perforation with Blunt Abdominal Trauma in Children

Gastrointestinal tract perforation is uncommon in children, accounting for <10% of cases of blunt abdominal trauma. Diagnosis of bowel perforation in children can be challenging due to poor diagnostic imaging accuracy. Intra-abdominal free air is found only in half of the children with bowel perforation. Ultrasound findings are nonspecific and suspicious for perforation in only two-thirds of cases. A computer tomography (CT) scan has a sensitivity and specificity of 50% and 95%, respectively. Surgical decisions should be made based on clinical examination despite normal CT results. Management of bowel perforation in children includes primary repair in 50-70% and resection with anastomosis in 20-40% of cases.

Traumatic pancreatitis

Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.