Pancreatic and gastrointestinal trauma in children.

Injuries to the pancreas and gastrointestinal tract following blunt abdominal trauma continue to be a significant cause of morbidity and mortality in the pediatric age group. Optimal treatment of these injuries is frequently hampered by considerable delays in diagnosis. Factors contributing to these delays include the location of much of the duodenum and the pancreas in the retroperitoneum resulting in an absence of initial symptoms and signs, the often trivial nature of some of the responsible blunt traumatic accidents, inappropriate child-parent or child-physician communication, failure to achieve a meaningful physical examination in uncooperative or unconscious patients, and false negative paracentesis. Eighty per cent of these injuries occurred in boys. Eleven of 16 patients with pancreatic trauma had pseudocysts. A persistently elevated serum amylase level was invariably noted and epigastric mass was palpable in eight patients. Significant delays in diagnosis were prevalent and pseudocysts was misdiagnosed as appendicitis in three cases. Internal drainage by cystgastrostomy or cystjejunostomy was effective operative treatment. In instances of acute pancreatic injuries, sump drains, gastrostomy, cholecystostomy, and total parenteral hyperalimentation were useful therapeutic adjuncts. There was one death for a 6.2 per cent mortality rate. Forty patients had gastrointestinal injuries involving the duodenum in 17, jejunum in 14, ileum in seven, and stomach in two. Perforations occured in 65 per cent of cases, obstructing hematomas in 30 per cent, and mesenteric avulsions in 5 per cent. Associated injuries were observed in 15 patients (37.5 per cent). Pain and tenderness were the only consistent findings. Upper gastrointestinal contrast studies were diagnostic of duodenal hematomas. Eighty per cent of perforations were managed by simple closures and 20 per cent by resection and anastomosis. Obstructing hematomas unassociated with other injuries may be expected to resolve without requiring operation in 50 per cent of patients managed conservatively. Complications occurred in 35 per cent of patients and the mortality rate was 12.5 per cent (five deaths).