Liver, spleen, and pancreas injury in children with blunt abdominal trauma
- David E Wesson, MD
David E Wesson, MD
- Professor of Surgery
- Baylor College of Medicine
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
This topic will review the diagnosis and management of liver, spleen, and pancreas injuries in children with blunt abdominal trauma. The general approach to blunt abdominal trauma in children and the diagnosis and management of hollow viscus injury following pediatric blunt abdominal trauma is discussed separately. (See "Overview of blunt abdominal trauma in children" and "Hollow viscus blunt abdominal trauma in children".)
Blunt abdominal trauma occurs in 10 to 15 percent of injured children . Solid organ injuries are common in children who sustain major trauma, with isolated injury to the spleen occurring most frequently . Injuries to the liver, spleen, and pancreas occur in two typical scenarios: isolated injury caused by a direct blow to the upper abdomen, or multi-system trauma caused by high-energy mechanisms (eg, motor vehicle or all-terrain vehicle crash, fall from a great height) . Isolated injuries to these organs are more common, but those associated with multi-system injury are more life-threatening with reported mortality as high as 12 percent .
The liver, spleen, and pancreas lie in the upper abdomen. They are partly protected by the ribs. This protection is less effective in children than in adults because the ribs are very pliable and because the liver and spleen may extend caudally beyond the ribs, especially in infants and toddlers. In addition, children have relatively larger viscera, less overlying fat, and weaker abdominal musculature. In children, almost all injuries to the liver, spleen, and pancreas are caused by blunt force. The mechanism can be a direct blow to the epigastrium with deformation of the abdominal wall, avulsion of the blood supply by rapid deceleration, puncture by a fractured rib, or crushing against the vertebral column.
Because the liver and spleen are highly vascular, injuries to these organs can cause fatal blood loss either from the parenchyma or the arteries and veins that supply them. Both perform essential physiologic functions, but the spleen can be removed completely to stop bleeding when all other approaches fail.
The liver has a dual blood supply via the hepatic arteries and the portal vein. Like the spleen, the liver parenchyma has a rich blood supply so that parenchymal injuries can lead to life-threatening blood loss. Blood flows from the posterior-superior surface of the liver into the IVC via the hepatic veins. Injuries to these vessels may lead to rapid exsanguination. The liver in children is relatively large and has less fibrous stroma than in adults. These differences make the child's liver more susceptible to laceration and bleeding after blunt abdominal trauma [4,5].
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- PERTINENT ANATOMY
- Physical examination
- Delayed clinical findings
- Laboratory studies
- Diagnostic peritoneal lavage
- DEFINITIVE MANAGEMENT
- Nonoperative management
- Angiographic embolization
- - Damage control surgery
- SUMMARY AND RECOMMENDATIONS