Liver, spleen, and pancreas injury in children with blunt abdominal trauma

INTRODUCTION — 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 are discussed separately. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization" and "Hollow viscus blunt abdominal trauma in children".)

EPIDEMIOLOGY — Blunt abdominal trauma occurs in 10 to 15 percent of injured children [1]. Solid organ injuries are common in children who sustain major trauma; isolated injury to the spleen is the most frequent [2]. Injuries to the liver, spleen, and pancreas occur in two typical scenarios: isolated injury caused by a direct blow to the upper abdomen, or multisystem trauma caused by high-energy mechanisms (eg, motor vehicle or all-terrain vehicle crash, fall from a great height) [1]. Isolated injuries to these organs are more common, but those associated with multisystem injury are more life threatening, with reported mortality as high as 12 percent [3].

PERTINENT ANATOMY — 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 parenchymal injuries can lead to life-threatening blood loss. Blood flows from the posterior-superior surface of the liver into the inferior vena cava 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].

By contrast, the parenchyma of the pancreas is not as vascular as the liver and spleen, so pancreatic trauma rarely causes major blood loss. Pancreatic trauma may cause the release of pancreatic juice, which is rich in digestive enzymes, causing local peritoneal and retroperitoneal inflammation.

STABILIZATION — Initial management of children with suspected injury to the liver, spleen, and/or pancreas should adhere to the Advanced Trauma Life Support protocol for diagnosis and treatment of immediately life-threatening injuries and appropriate resuscitation (table 1). After the patient has been assessed, resuscitated, and stabilized, the patient should receive ongoing care directed by a trauma surgeon with pediatric expertise, when available. Because optimal care and outcomes occur when the critically injured child is initially resuscitated and subsequently managed in a pediatric trauma center (PTC), it is preferable to provide initial care in such facilities from the outset, whenever possible, or to arrange transfer to a PTC for ongoing management. (See "Trauma management: Approach to the unstable child", section on 'Definitive care'.)

Hemodynamically unstable children with blunt abdominal injury who remain unstable following adequate resuscitation (eg, normal saline or Ringer's lactate, 40 mL/kg intravenously, maximum total volume 2 L, followed by packed red blood cells, 10 to 20 mL/kg intravenously) warrant emergency exploratory laparotomy or, in selected patients, angioembolization [6-8]. (See 'Definitive management' below.)

In most instances, children with liver or spleen injuries are managed nonoperatively. The management for pancreatic injuries may be operative or nonoperative. (See 'Definitive management' below.)

EVALUATION — Initial evaluation of pediatric trauma patients should follow the standard Advanced Trauma Life Support protocol. Life-threatening injuries that compromise airway, breathing, and circulation should be addressed first (table 1). Assessment for abdominal injury in the stable patient should take place as part of the secondary survey. (See "Trauma management: Approach to the unstable child", section on 'Abdomen'.)

The diagnosis of injuries to the liver, spleen, and pancreas should be made on the basis of clinical assessment by history and physical examination and confirmed by diagnostic imaging. These injuries cause harm through two basic mechanisms:

●Bleeding from the parenchyma of the spleen and liver or the major blood vessels that supply these organs

●Peritonitis from the release of pancreatic juice

The clinical assessment of children with blunt abdominal trauma is primarily the search for evidence of bleeding or peritonitis.

History — There is usually a history of a direct blow to the trunk over the upper abdomen (bicycle handlebar, hockey stick jammed between the boards and abdomen, helmet "spearing" in football) or a high-energy mechanism such as a high-speed motor vehicle crash or a fall from a great height. Children with solid organ injuries often, but not always, complain of pain that may be localized to the area over the injured organ or more generalized. With pancreatic trauma, the pain may radiate to the back, and with splenic involvement, to the left shoulder (Kehr sign). In patients with multisystem trauma, a decreased level of consciousness or injuries to other parts of the body may mask abdominal involvement. A seemingly minimal force may injure children with preexisting hepatomegaly or splenomegaly. Child abuse should also be suspected in children in whom the history is absent or inadequate to explain the degree of injury. (See "Physical child abuse: Recognition", section on 'Unexplained major trauma'.)

Physical examination — The clinical features of solid organ injury may include findings of hypovolemic shock (eg, tachycardia, prolonged capillary refill time, pallor, altered mental status, decreased urine output, hypotension), abdominal contusions, or tenderness over the upper abdomen. The following findings should be noted on abdominal examination:

●Abdominal tenderness, specific patterns may be associated with the injured organ:

•Right upper quadrant tenderness or superior midline abdominal tenderness – Liver or pancreas injury

•Left upper quadrant tenderness – Splenic injury

•Epigastric tenderness – Pancreas injury

●Abdominal wall ecchymosis or abrasions ("seat belt sign" or midline abdominal bruise from a bicycle handlebar)

●Abdominal distension

Gastric decompression with a nasogastric or orogastric tube facilitates abdominal examination in the multiple trauma patient and reduces the risk of aspiration of gastric contents [9]. The abdominal examination is difficult to interpret in patients with impaired neurologic status from head or spinal cord injury or substance abuse and is unreliable in determining the need for further evaluation and intervention in a significant proportion of these patients. For example, a case series of 71 children with head injury and intra-abdominal injury discovered on computed tomography (CT) or at laparotomy reported a negative physical examination in 30 patients (42 percent) [10].

If it occurs, blood loss great enough to cause shock will usually occur within 24 hours of the time of injury. For example, an observational study of 1813 children with solid organ injuries found that median time to operation was 2.4 hours, with 90 percent of the 120 children undergoing surgical intervention within 24 hours [11]. After 24 hours, the risk of massive bleeding decreases.

In addition to solid organ injuries, a linear bruise across the abdomen from a seat belt is associated with injuries to the bowel, retroperitoneal vessels, spine, and spinal cord [12]. (See "Hollow viscus blunt abdominal trauma in children", section on 'Lap seat belt injury'.)

Delayed clinical findings — In some cases, patients may present with delayed complaints and physical findings. Although it is rare, patients with delayed presentation of splenic injury (hemorrhage from the ruptured spleen more than 48 hours after trauma) can present with left subcostal pain, left shoulder pain, abdominal distension, rigidity, rebound tenderness, fullness in the left upper quadrant, or anemia [13-16]. Patients with delayed presentation of pancreatic trauma may have findings suggestive of pancreatic pseudocyst, including epigastric pain, palpable abdominal mass, peritoneal findings, and elevated lipase or amylase [17].

Laboratory studies — The indications for performing specific laboratory studies in children with blunt abdominal trauma are discussed in detail separately. (See "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Laboratory evaluation'.)

Hematologic studies, serum chemistries, and urinalysis are adjuncts to diagnosis and are not substitutes for clinical assessment and further imaging of children with suspected trauma to the liver, spleen, or pancreas. Of the studies often obtained in these children, the following are most likely to assist with acute patient management:

●Hematocrit

●Type and cross for packed red blood cells

●Rapid blood glucose

●Liver enzymes (aspartate aminotransferase [AST] and alanine aminotransferase [ALT])

●Serum amylase and lipase

●Blood lactate

●Urinalysis

Of these, an initial hematocrit and blood for type and cross are most essential, especially in children with signs of hypovolemic shock.

Other studies commonly obtained in unstable pediatric blunt trauma victims include (see "Trauma management: Approach to the unstable child", section on 'Laboratory studies'):

●Complete blood count with differential

●Prothrombin time, partial thromboplastin time, and international normalized ratio

●Serum electrolytes

●Serum blood urea nitrogen and creatinine

●Arterial or venous blood gas

●Blood ethanol level and urine screen for drugs of abuse (adolescents)

●Urine pregnancy test (postmenarcheal females)

Laboratory studies have limited sensitivity and negative predictive value for blunt abdominal trauma, including liver, spleen, or pancreas injury. An observational study evaluated the test characteristics of the "routine trauma panel," including complete blood count, serum electrolytes, glucose, liver enzymes, prothrombin time, partial thromboplastin time, and urinalysis in 83 of 241 children with blunt abdominal trauma and evidence of intra-abdominal injury on CT [18]. No single test had acceptable sensitivity or negative predictive value to be helpful in screening such patients. In this study, glucose and AST had the highest sensitivity (75 and 63 percent, respectively), and lipase had the highest positive predictive value (75 percent).

Imaging — Abdominal and pelvic CT with intravenous contrast is the preferred initial diagnostic imaging modality to detect intra-abdominal injury in hemodynamically stable children who have sustained blunt abdominal trauma. CT is sensitive and specific in diagnosing liver and spleen injuries, which may be managed nonoperatively. CT with intravenous contrast alone is less sensitive for detecting pancreas injuries. (See 'Liver' below and 'Spleen' below and 'Pancreas' below.)

Indications for abdominal CT scan (only for the hemodynamically stable patient) include the following findings that are frequently associated with serious liver, spleen, or pancreatic injuries (see "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Abdominal and pelvic CT'):

●Abdominal pain or tenderness

●Abdominal wall bruising (eg, seat belt sign, handlebar bruising, or other bruises concerning for child abuse (table 2) (see "Hollow viscus blunt abdominal trauma in children", section on 'Lap seat belt injury')

●Positive focused assessment with sonography for trauma (FAST) examination

●Initial serum AST >200 IU/L or ALT >125 IU/L

●Initial elevated serum lipase or amylase

●Serious thoracic trauma based upon physical examination findings or chest radiograph

●Inability to perform adequate abdominal examination or serial abdominal examinations (eg, head injury with altered mental status, very young or nonverbal child, or planned general anesthesia) in a patient with history or mechanism suggestive of intra-abdominal injury

FAST is a rapid ultrasound examination of four abdominal locations: right upper quadrant, left upper quadrant, subxiphoid region, and pelvis. The primary utility of this examination is for the detection of hemopericardium and/or intraperitoneal fluid secondary to intra-abdominal injury in the hemodynamically unstable patient. For example, unstable patients with blunt abdominal trauma and intraperitoneal fluid on FAST may warrant immediate operative intervention in lieu of CT of the abdomen. In the stable patient, the presence of intraperitoneal fluid on FAST indicates the need for abdominal CT. However, a negative FAST does not have adequate sensitivity or negative predictive value to exclude intra-abdominal injury, especially solid organ injury. (See "Trauma management: Approach to the unstable child", section on 'e-FAST (extended focused assessment with sonography for trauma)'.)

Contrast-enhanced sonography (CEUS) using blood-pool agents appears to have higher sensitivity for solid organ injury in children than FAST [19]. CEUS is particularly suited for evaluation of hemodynamically stable patients who have sustained low- to moderate-energy blunt abdominal trauma. Studies have shown the utility of CEUS as an initial imaging exam to evaluate for solid organ injury, an adjunctive exam to delineate indeterminate findings on CT, or as a follow-up evaluation of known injury [20]. Although a promising imaging modality for future use that may further limit the use of CT in blunt abdominal trauma evaluation, its accuracy is user dependent, and further study is needed to determine appropriate indications in children.

Laparoscopy — Although uncommonly performed, laparoscopy may be a useful adjunct to CT and FAST in children with blunt abdominal trauma, both to confirm a suspected diagnosis and to treat some injuries definitively [21,22].

Diagnostic peritoneal lavage — Diagnostic peritoneal lavage (DPL) in children has largely been supplanted by FAST, CT of the abdomen and pelvis, and laparoscopy. (See "Trauma management: Approach to the unstable child", section on 'e-FAST (extended focused assessment with sonography for trauma)' and "Trauma management: Approach to the unstable child", section on 'Abdominal CT' and "Trauma management: Approach to the unstable child", section on 'Laparoscopy'.)

DPL is not performed in hemodynamically stable children with suspected injury to the liver, spleen, or pancreas because most children with solid organ injury are managed nonoperatively, and intra-abdominal bleeding may cause a false-positive test in a significant number of such patients. Rarely, DPL may be performed to determine the need for laparotomy in a hemodynamically unstable patient with a suspected emergency, operative head injury, although laparoscopy is preferred for this indication by many surgeons.

CLASSIFICATION — The classification systems for liver, spleen, or pancreas injury are typically based upon CT images (table 3 and table 4 and table 5) because most of these injuries are treated nonoperatively. However, for liver and spleen injuries, the decision to operate is primarily based upon hemodynamic stability, not CT findings [8]. (See 'Definitive management' below.)

DEFINITIVE MANAGEMENT

Principles of nonoperative management — Clinically stable children with isolated liver and spleen injuries, grades I through IV (table 3 and table 4), should receive nonoperative management provided by a pediatric surgeon. Children with grade V injury usually warrant surgical intervention, but there are exceptions based on the clinical course. Those patients with grade V injuries that remain hemodynamically stable and do not require ongoing blood replacement can be safely managed nonoperatively. The clinical course is more important than the computed tomography (CT) grade in deciding when to operate. Hemodynamically stable patients can be admitted to an acute care ward, but patients who were initially hemodynamically unstable or anemic require intensive care unit monitoring. In more than 90 percent of cases, management of patients with liver or splenic injuries requires only admission to the hospital for monitoring of vital signs, hematocrit, and urinary output, combined with temporary rest and restricted activity [11,23-25]. By contrast, 18 to 50 percent of pancreatic injuries receive surgery at some point; however, management for some pancreatic injuries is quite variable among surgeons because evidence is limited to identify the best approach [23,26]. (See 'Pancreas' below.)

Up to 21 percent of patients with liver and/or spleen injuries require a blood transfusion [24,27]. Patients who develop hypovolemic shock or a significant drop in hemoglobin and hematocrit (eg, hemoglobin <7 g/dL) should receive blood as necessary. Hemodynamic instability (lack of sustained improvement in hemodynamic stability after 20 mL/kg of packed red blood cells) or recurrent hypotension indicative of ongoing blood loss requiring >40 mL/kg of packed red blood cells (approximately half the blood volume) is the primary indication for operative intervention or angioembolization [6,8].

Evidence-based clinical practice guidelines for the treatment of clinically stable patients with isolated liver and spleen injuries, grades I through IV, are summarized in the tables (table 3 and table 4) and are based on review of 832 children cared for at 32 pediatric centers in the United States [8]. Observational studies suggest that hospital length of stay can be reduced even further, especially for low-grade injuries [8,28,29]. In addition, management of these patients according to hemodynamic stability rather than grade of injury has become the recommended approach [8]. Use of the American Pediatric Surgical Association clinical practice guidelines has been associated with lower resource utilization without evidence of significant risk [30].

Angiography and embolization — Although angiographic embolization of vascular injuries to the spleen and liver is widely used in adults, experience in children is limited to isolated case reports and case series [24,30-34]. Based upon this limited evidence, angiography may be an alternative to surgery in hemodynamically unstable children with blunt liver or spleen injury with an arterial blush on CT imaging [30]. However, prophylactic embolization in stable patients with an arterial blush on CT is not indicated.

Organ-specific management

Liver — Although the diagnosis of liver injuries is best established by contrast-enhanced CT of the abdomen (image 1), the management is dictated by the clinical course. Patients who remain hemodynamically stable can be treated nonoperatively. This is possible in >90 percent of cases [35]. If shock that does not respond to volume replacement or massive continuing blood loss occurs, laparotomy is indicated to stop the bleeding. The Pediatric Trauma Society has provided a visual guideline for the management of blunt liver and spleen injury [36].

Damage-control surgery — Operations for liver trauma can be very difficult and are best performed by experienced trauma surgeons. Exsanguinating hemorrhage may occur, so the surgeon and anesthesiologist must be prepared to respond to massive blood loss. Direct control of the bleeding is ideal, but this may not be possible. Massive bleeding may lead to shock, hypothermia, coagulopathy, hypocalcemia, and lactic acidosis. In this situation, damage control with perihepatic packing to tamponade the bleeding, temporary closure of the abdomen, and return to the intensive care unit to restore physiological stability is currently the preferred course of action (table 6) [37]. Once physiologic stability is achieved, the child undergoes reoperation with removal of packing and blood clots, definitive repair of injuries, and abdominal closure. In one small series of 22 children with refractory hepatic hemorrhage (13 due to blunt trauma), damage-control surgery stopped hemorrhage in 21 patients, and 18 patients survived [38].

Spleen — Contrast-enhanced CT of the abdomen is the best way to establish the diagnosis of splenic injury (image 2 and image 3). However, the management is dictated by the clinical course, not by the grade of injury present on the CT, including the presence or absence of an arterial blush (image 4) [39-43]. Patients who remain hemodynamically stable can be treated nonoperatively. This is possible in >90 percent of cases [11,31,44]. There is no evidence that nonoperative treatment increases the need for blood transfusion, lengthens hospital stay, or results in missed intra-abdominal injuries. Less than 5 percent of patients with isolated splenic injuries ever require a blood transfusion [27]. The Pediatric Trauma Society has provided a visual guideline for the management of blunt liver and spleen injury [36].

There are no generally accepted guidelines defining when operative intervention is indicated in blunt splenic trauma. One criterion reported more than 20 years ago is the need to replace more than half of the estimated circulating blood volume (approximately 40 mL/kg packed red blood cells) [6]. No other specific indication has been suggested. However, arterial embolization is an alternative to surgery for selected hemodynamically stable patients with ongoing blood transfusion requirements. (See 'Angiography and embolization' above.)

Children with a spleen injury who do require operative intervention almost always declare themselves in the first 12 hours after injury [11]. Delayed rupture of the spleen in children is rare [45].

At operation, attempts should be made to salvage the spleen, especially when there are no other significant intra-abdominal injuries. In some cases, this can be accomplished by direct repair (splenorrhaphy) or partial splenectomy (leaving at least one-third of the spleen with an intact arterial blood supply). However, splenectomy is often the best option, especially when:

●There are other significant intra-abdominal injuries that require repair

●The patient is hemodynamically unstable

●The spleen is damaged beyond repair

Splenectomy patients must be informed about the risk of post-splenectomy infection. (See "Patient education: Preventing infection in people with impaired spleen function (Beyond the Basics)".)

Prevention of sepsis in the asplenic patient includes immunization, antibiotic prophylaxis, and anticipatory antibiotics when patients develop a febrile illness. (See "Prevention of infection in patients with impaired splenic function".)

Pancreas — Major pancreatic injuries are much less common than liver or spleen injuries. The clinical features include a history of a direct blow to the epigastrium with local pain and tenderness on examination. The serum amylase and/or lipase are usually elevated [46]. The most useful test for suspected pancreatic trauma is CT with IV contrast with fine cuts through the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) may provide useful additional information when a major duct disruption is suspected based upon clinical findings and CT imaging [47-50]. Pancreatic injuries fall into three main groups:

●Injury without major ductal disruption – This injury type comprises the largest group of patients with pancreatic trauma. Most cases have simple contusions or hematomas, although some probably have parenchymal disruption. The diagnosis is usually suspected on the basis of elevated serum amylase and lipase levels and is confirmed by CT, which shows swelling and hemorrhage in and around the pancreas but no evidence of transection or other major parenchymal or ductal disruption (AAST grades I and II). The treatment is nonoperative, including restriction of oral intake initially, intravenous hydration, and parenteral nutrition. For example, in a case series of 43 children with pancreatic injury after blunt trauma, the 18 children with grade I injuries were all managed nonoperatively without complications [51].

●Injury with major ductal disruption – Major pancreatic ductal disruption is difficult to recognize, although it may be suggested by CT. Reports have supported the use of ERCP or MRCP to confirm the diagnosis [48,49,51,52]. The Pediatric Trauma Society provides a clinical pathway for management of these injuries.

The management of grade III injuries, in which the pancreatic duct is disrupted at the body or tail (commonly due to handlebar injury), is highly variable, and evidence is lacking and inconsistent to suggest one approach over another for these rare injuries [53,54]. Some pediatric surgeons follow the adult pancreatic trauma philosophy of operative management with distal pancreatectomy, whereas others prefer nonoperative management (image 5) [55,56].

By contrast, proximal pancreatic injuries (grades IV and V) are more commonly managed nonoperatively, with or without endoscopic stent placement, because operation would require significant pancreatic resection or pancreatoduodenectomy. For all high-grade pancreatic injuries, if nonoperative management is chosen, then observation with early oral feeding is recommended. Further imaging should be avoided unless symptoms develop [57].

For the most part, these injuries almost always resolve, although the course may be prolonged over many weeks. Acute organized fluid collections develop in up to 50 percent of children with ductal disruption who are initially treated nonoperatively. Some of these go on to becoming symptomatic pseudocysts, while others resolve spontaneously. These patients can present with anorexia, vomiting, weight loss, abdominal pain and tenderness, and sometimes a palpable upper-abdominal mass several weeks postinjury. CT or ultrasound can be used to confirm the diagnosis (image 6). The treatment is conservative with gut rest, parenteral nutrition, and observation by serial ultrasound. Some resolve spontaneously, while the rest usually respond to external (percutaneous) drainage, or internal drainage (cyst-gastrostomy) if they persist after a period of four to six weeks [58,59]. Some experts recommend endoscopic pancreatic duct stenting [48].

Based upon a small, multicenter case series, endoscopic ductal stenting may successfully treat strictures but does not appear to alter the consequences of ductal leakage [60].

PITFALLS — The most common error in the management of liver and spleen injuries is failure to recognize life-threatening bleeding at an early stage. The critical period for bleeding is the first 12 hours after injury. Delayed hemorrhage is a rare event.

OUTCOMES — The short- and long-term outcome depends mainly on the presence or absence of associated injuries. Early mortality is related to the patient's overall severity of injury and occurs in up to 12 percent of children with blunt abdominal injury and multisystem trauma [3]. If major bleeding does not occur, or if it is treated promptly, a rapid and complete recovery of organ function is the rule.

Rare late complications include hematobilia or infected biloma after liver trauma [61] and splenic pseudocyst after splenic trauma [62,63]. Late sequelae of pancreatic trauma primarily consist of pseudocyst formations, especially in patients with high-grade injuries who were managed nonoperatively. Fistulae can also develop.

Of all injuries, the only known long-term potential complication is the small but definite risk of postsplenectomy sepsis in patients after splenectomy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma".)

SUMMARY AND RECOMMENDATIONS

●Epidemiology and mechanism of injury – Liver and spleen injuries are the most common, potentially life-threatening intra-abdominal injuries in children who sustain blunt trauma. Pancreatic injury is less common. Mechanisms of injury include direct blow to the trunk over the upper abdomen (eg, bicycle handlebar, hockey stick jammed between the boards and abdomen, helmet "spearing" in football) or a high-energy mechanism such as a high-speed motor vehicle crash or a fall from a great height. Child abuse should also be suspected in children in whom the history is absent or inadequate to explain the degree of injury. (See 'Epidemiology' above and 'History' above.)

●Stabilization – Initial evaluation of pediatric trauma patients should follow the standard Advanced Trauma Life Support protocol, with life-threatening injuries that compromise airway, breathing, and circulation addressed first (table 1). Whenever possible, the child should receive care directed by a pediatric trauma surgeon in a pediatric trauma center (PTC). (See 'Stabilization' above and "Trauma management: Approach to the unstable child", section on 'Abdomen'.)

Hemodynamically unstable children with blunt abdominal injury who remain unstable following fluid resuscitation and blood transfusion warrant emergency exploratory laparotomy or, in selected patients, angioembolization. Unstable children with blunt abdominal trauma and intraperitoneal fluid on extended focused assessment with sonography for trauma (e-FAST) may warrant operative intervention in lieu of computed tomography (CT) of the abdomen and pelvis. (See 'Definitive management' above and "Trauma management: Approach to the unstable child", section on 'e-FAST (extended focused assessment with sonography for trauma)'.)

●Evaluation – Children with liver, spleen, or pancreas injury usually have a history of a direct blow to the trunk over the upper abdomen (bicycle handlebar, hockey stick jammed between the boards and abdomen, helmet "spearing" in football) or a high-energy mechanism, such as a high-speed motor vehicle crash or a fall from a great height. Clinical findings include local pain and tenderness over the upper abdomen, shoulder pain, or signs of shock from blood loss. Altered mental status or multiple traumatic injuries may mask significant injury to the liver, spleen, or pancreas. (See 'History' above and 'Physical examination' above.)

●Laboratory studies – An initial hematocrit and blood for type and cross are the most essential laboratory studies, especially in children with signs of hypovolemic shock. The following laboratory studies are also warranted in children with blunt abdominal trauma and suspected intra-abdominal injury (see 'Laboratory studies' above and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Laboratory evaluation'):

•Rapid blood glucose

•Complete blood count (CBC)

•Arterial or venous blood gas

•Serum transaminases (alanine aminotransferase [ALT] and aspartate aminotransferase [AST])

•Serum electrolytes, creatinine, and blood urea nitrogen

•Amylase and lipase

•Prothrombin time (PT), partial thromboplastin time (PTT)

•Urinalysis

●Imaging – In hemodynamically stable children with findings of serious intra-abdominal injury, abdominal CT with intravenous contrast is the single most useful initial diagnostic test for liver (image 1), spleen (image 2 and image 3), and pancreas (image 5 and image 6) injuries. (See 'Imaging' above.)

CT can be highly suggestive of major pancreatic injury but is not definitive. If confirmation is required to determine whether operation is necessary, endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate if available. Alternatively, magnetic resonance cholangiopancreatography (MRCP) may provide additional information (see 'Pancreas' above). If the surgeon chooses to manage all pancreatic injuries nonoperatively, then no further imaging or ERCP is necessary to confirm duct disruption.

●Nonoperative management – Management of blunt liver, spleen, or pancreatic injury is dictated by the clinical course, not by the grade of injury present on the CT. Most children with isolated blunt liver, spleen, or pancreas injuries can be managed nonoperatively. The Pediatric Trauma Society has provided a visual guideline for the management of blunt liver and spleen injury and a clinical pathway for management of pancreatic injuries. (See 'Principles of nonoperative management' above and 'Organ-specific management' above.)

●Surgery – The main indication for surgery is massive or continuing blood loss in patients with liver or spleen injury that is unresponsive to administration of intravenous fluids and blood, or evidence of major duct disruption in patients with pancreas injury. (See 'Principles of nonoperative management' above.)

●Angiography and embolization – Selected patients may be managed with angiography and embolization, especially those with ongoing bleeding. (See 'Liver' above and 'Spleen' above and 'Pancreas' above and 'Angiography and embolization' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges David E Wesson, MD, who contributed to earlier versions of this topic review.