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Solid organ injury in children (spleen, liver, kidney, pancreas)

A haemodynamically stable child with a splenic or liver injury is almost always managed without surgery, whatever the CT grade — the decision is made by the clinical state, not by the image.

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Why it matters in the exam

Non-operative management (NOM) succeeds in more than 90% of children with blunt splenic and liver injury. The APSA guideline and the ATOMAC pathway state that admission, bed rest and blood tests are set by haemodynamic stability and not by grade; an unstable child receives blood, and failure of non-operative management is defined as instability despite transfusion — in practice after about 40 mL/kg of blood products — and then surgery follows. Routine repeat imaging is not needed in a child who is improving; repeat imaging is done for new symptoms (for example suspected pseudoaneurysm).

Activity restriction after splenic or liver injury is commonly "grade plus two weeks" (for example grade 3 — five weeks without contact sport). Splenic preservation matters especially in children because of the risk of overwhelming post-splenectomy infection (OPSI). Angio-embolisation is used less in children than in adults, mainly with contrast extravasation and a child not responding to blood. Renal injury is usually managed non-operatively as well.

Pancreatic and duodenal injury follow a bicycle handlebar blow. A duodenal wall haematoma presents with vomiting a few days after the injury and is treated with a gastric tube and parenteral nutrition until it resolves, usually within 2–3 weeks. A pancreatic duct transection in the body of the pancreas is treated by distal pancreatectomy or non-operatively, and a late complication may be a pseudocyst. Hollow viscus injury (a "seat-belt sign") may be found late — worsening pain, fever and free air require surgery.

Key points

• Stable — non-operative, whatever the grade.
• Failure — instability after about 40 mL/kg of blood.
• Activity restriction: grade plus two weeks.
• Handlebar — pancreas and duodenum; seat belt — bowel.
• Preserve the spleen.

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Sources

• APSA Trauma Committee: Pediatric solid organ injury guideline (Gates et al.), 2019 — Nonoperative management, admission and activity restriction
• ATOMAC (Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium) pathway for pediatric blunt liver and spleen injury, 2015 — Hemodynamic-based management

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.