Successful endoscopic management of a pediatric intrapancreatic common bile duct stricture following blunt pancreatic trauma: A case report
Medical College of Wisconsin, Milwaukee, Wisconsin, USA
Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
Abstract
Pancreatic and biliary tract injuries from blunt abdominal trauma are rare in children. Common bile duct (CBD) strictures secondary to pancreatic trauma are even more uncommon, and management traditionally involves surgery. We report a 9‐year‐old boy who developed a severe distal intrapancreatic CBD stricture after blunt pancreatic trauma during an all‐terrain vehicle (ATV) accident. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a 25 mm stricture in the lower CBD. The stricture resolved after two sessions of ERCP with biliary stenting, avoiding surgery. This case highlights a rare but significant delayed biliary complication of pediatric blunt pancreatic trauma. Early recognition and minimally invasive endoscopic intervention can achieve successful stricture resolution and may prevent the need for surgical repair. This case adds to the scarce literature on pediatric traumatic pancreatitis–associated distal CBD stricture managed successfully with ERCP and stenting.
Untitled section
Keywords: minimally invasive therapy, nonoperative management, pancreaticobiliary injury, pediatric endoscopic retrograde cholangiopancreatography (ERCP), traumatic biliary obstruction
Article notes
Untitled section
Revised 2025 Nov 19; Received 2025 Jul 23; Accepted 2025 Nov 22; Collection date 2026 May.
1.INTRODUCTION
Pancreatic and biliary tract injuries from blunt abdominal trauma are uncommon in children, largely due to the retroperitoneal location of the pancreas. 1 Pancreatic injury occurs in 0.3% of pediatric blunt trauma, 2 while biliary tract injuries account for only 0.09%. 1 Most reported benign pediatric biliary strictures are associated with cholecystectomy, liver transplantation, primary sclerosing cholangitis, or chronic pancreatitis. 3
We describe a case of a 9‐year‐old boy who developed a severe intrapancreatic common bile duct (CBD) stricture following pancreatic head trauma, successfully managed with endoscopic stenting.
2.CASE REPORT
A 9‐year‐old previously healthy male presented with jaundice 3 weeks after sustaining blunt abdominal trauma during an all‐terrain vehicle (ATV) accident. Initial injuries included a grade 2 hepatic laceration, hepatic hematoma, pancreatic contusion with mild pancreatitis, and grade 2 renal laceration. The patient was admitted to the intensive care unit (ICU) for observation and discharged 5 days later in clinically stable condition.
Ten days post‐injury, the patient presented to the emergency department (ED) with abdominal pain; a computed tomography (CT) scan demonstrated improving hepatic and pancreatic injuries and edema in the head of the pancreas. The patient returned with painless jaundice and acholic stools 9 days later. Laboratory studies demonstrated a cholestatic liver injury pattern (Table 1). The physical examination was unremarkable without hepatosplenomegaly.
| Parameter | Reference range and units | 10/19/24 (Injury) | 10/29/24 (Emergency department visit) | 11/6/24 (Emergency department visit, jaundice) | 11/11/24 (Pre‐ERCP) | 11/12/24 (Post‐ERCP) | 11/29/24 (17 days post‐ERCP) |
|---|---|---|---|---|---|---|---|
| AST | 16–41 IU/L | 201 | 271 | 71 | 141 | 144 | 29 |
| ALT | 10–19 IU/L | 149 | 527 | 151 | 210 | 196 | 39 |
| Total bilirubin | 0.0–1.5 mg/dL | — | 0.7 | 4.2 | 5.1 | 4.1 | 0.9 |
| Conjugated bilirubin | 0.0–0.4 mg/dL | — | — | 3.9 | 2.0 | 1.6 | 0.5 |
| GGT | 15–85 IU/L | — | — | 135 | 96 | — | 31 |
| Alkaline phosphatase | 140–371 IU/L | 469 | 491 | 699 | 630 | 570 | 447 |
| Lipase | 0–64 U/L | 224 | 39 | 25 | — | — | — |
The patient was transferred to a tertiary pediatric hospital and underwent an endoscopic ultrasound (EUS) and ERCP, which demonstrated a dilated CBD measuring 10 mm, dilation of the intrahepatic biliary tree, and peripancreatic edema. ERCP revealed a 25 mm localized stricture of the lower third of the CBD with upstream biliary dilation and mild pancreatic duct narrowing (Figure 1). An 8.5 Fr × 7 cm plastic biliary stent was placed across the biliary stricture.
Within 24 h, significant biochemical improvement was observed, and 17 days post‐ERCP, laboratory values near normalized (Table 1). A follow‐up ERCP performed 2 months later demonstrated 90% resolution of the CBD stricture (Figure 2). Mild residual narrowing was noted during balloon dilation, and a 10 Fr by 5 cm plastic stent was placed. Subsequent CT imaging confirmed resolution of pancreatic head edema, and the stent was successfully removed after 2 months without recurrence of symptoms at 12‐month follow‐up.
3.DISCUSSION
Blunt abdominal trauma can cause pancreatic and biliary injuries; however, these injuries remain rare in pediatric populations. Strictures may form due to inflammation, fibrosis, hematoma compression, or vascular compromise following ductal injury. Intrapancreatic CBD strictures may result from peripancreatic edema and tractional forces on the fixed intrahepatic bile ducts. 4
Reports of delayed biliary strictures post‐trauma are limited. One case in 2009 described a 15‐year‐old who developed intrahepatic biliary stenosis after colliding with a bare steel cable; ERCP provided temporary relief but restenosis later occurred. 5 Another case involved a 13‐year‐old who required a hepaticojejunostomy for a mid‐CBD injury after sustaining a helmet blow to the abdomen. 6 A third case involved a 3‐year‐old who sustained blunt abdominal trauma in a car accident and presented a month later with jaundice and severe stricture in the lower CBD. She was successfully treated with a choledochoduodenostomy. 7
ERCP is the primary therapeutic modality for managing benign and malignant biliary strictures. Using a duodenoscope, selective guidewire access allows sphincterotomy and cholangiography to define the stricture length, location, and severity. Therapeutic options include balloon dilation and stenting with either plastic biliary stents (typically exchanged every 3 months) or fully covered self‐expanding metal stents, which can remain in place for up to 12 months depending on design and indication. If a stricture cannot be resolved after multiple stenting attempts, surgical referral is warranted.
EUS use in pediatrics is expanding. Radial echoendoscopes provide diagnostic and linear echoendoscopes provide both diagnostic and therapeutic capability, with superior accuracy to CT, ultrasound, and MRI for detecting microlithiasis, sludge, ampullary pathology, and chronic pancreatitis. In this case, EUS contributed to stricture characterization, while ERCP enabled definitive therapy.
Endoscopic management of traumatic biliary strictures is increasingly reported. Although traditionally bile duct injuries were managed surgically, the evolution of endoscopic and radiologic techniques has enabled less invasive alternatives with favorable outcomes. This is consistent with the nationwide study from 2011 to 2021 that reported a significant rise in the use of ERCP in pediatric trauma centers, from 6.1% to 19%, reflecting the growing preference for minimally invasive approaches. 8 As demonstrated in a prior study of five pediatric patients with blunt bile duct injuries, ERCP with stenting and/or percutaneous drainage was successfully employed even after multiple failed laparotomies, underscoring the safety and efficacy of nonoperative intervention. 9
4.CONCLUSION
This case illustrates a rare but important delayed complication of pediatric blunt pancreatic trauma. Prompt recognition, careful imaging, and minimally invasive management with ERCP and stenting can successfully treat traumatic CBD strictures and may obviate the need for surgery.
CONFLICT OF INTEREST STATEMENT
Diana G. Lerner serves on the advisory boards for EvoEndo. The remaining authors declare no conflicts of interest.
ETHICS STATEMENT
Informed parental consent was obtained prior to submission.
REFERENCES
Untitled section
References
- 1. Soukup ES, Russell KW, Metzger R, Scaife ER, Barnhart DC, Rollins MD. Treatment and outcome of traumatic biliary injuries in children. J Pediatr Surg. 2014;49(2):345‐348. 10.1016/j.jpedsurg.2013.10.011
- 2. Englum BR, Gulack BC, Rice HE, Scarborough JE, Adibe OO. Management of blunt pancreatic trauma in children: review of the national trauma data bank. J Pediatr Surg. 2016;51(9):1526‐1531. 10.1016/j.jpedsurg.2016.05.003
- 3. Raman SP, Fishman EK. Abnormalities of the distal common bile duct and ampulla: diagnostic approach and differential diagnosis using multiplanar reformations and 3D imaging. Am J Roentgenol. 2014;203(1):17‐28. 10.2214/AJR.13.11288
- 4. Park DH, Kim MH, Kim TN, et al. Endoscopic treatment for suprapancreatic biliary stricture following blunt abdominal trauma. Am J Gastroenterol. 2007;102(3):544‐549. 10.1111/j.1572-0241.2006.01026.x
- 5. Takamizawa S, Nozaki N, Aoyama N, Nishijima E, Muraji T. Endoscopic retrograde biliary drainage for posttraumatic intrapancreatic biliary stenosis in a child. J Pediatr Surg. 2009;44(9):e25‐e28. 10.1016/j.jpedsurg.2009.06.010
- 6. Kendall RS. Acquired bile duct stricture in childhood related to blunt trauma. Report of a case and review of the literature. Am J Dis Child. 1980;134(9):851‐854. 10.1001/archpedi.1980.02130210035010
- 7. Mousavi SA, Karami H. Cholestasis in a three year‐old child following abdominal blunt trauma: a case report. Trauma Mon. 2013;18(3):139‐140. 10.5812/traumamon.12611
- 8. Katsura M, Ikenoue T, Aoki M, et al. Recent changes in the management of high‐grade blunt pancreatic injury in children: a nationwide trend analysis. J Am Coll Surg. 2024;238(6):1106‐1114. 10.1097/XCS.0000000000001033
- 9. Almaramhi H, Al‐Qahtani AR. Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention. J Pediatr Surg. 2006;41(5):943‐945. 10.1016/j.jpedsurg.2006.01.057