Which abdominal organ is most likely damaged in a patient with upper abdominal pain and tenderness after a handlebar injury, with an inconclusive Focused Assessment with Sonography for Trauma (FAST) exam and tachycardia?

Pancreatic Injury is Most Likely in This Handlebar Trauma Case

In a patient with upper abdominal pain following handlebar injury and an inconclusive FAST exam, pancreatic injury (Option C) is the most likely diagnosis, and this patient requires immediate contrast-enhanced CT imaging to definitively identify the injury.

Clinical Reasoning for Pancreatic Injury

Mechanism-Specific Injury Pattern

• Handlebar injuries characteristically cause pancreatic trauma due to the direct compression of the pancreas against the vertebral column from focal anterior abdominal impact 1
• The upper abdominal location of pain is anatomically consistent with pancreatic injury, which classically presents with epigastric tenderness 1
• Pancreatic injuries are notorious for discordance between injury severity and initial clinical presentation, meaning significant injury can exist despite relatively stable vital signs (explaining the near-normal vitals with only tachycardia) 1

Why FAST is Inconclusive

• FAST has poor sensitivity (68-91%) for detecting all intra-abdominal injuries and frequently misses bowel and pancreatic injuries 2
• Pancreatic injuries often do not produce immediate significant hemoperitoneum, making FAST particularly unreliable for this organ 1
• The American College of Emergency Physicians emphasizes that negative or inconclusive FAST does not exclude significant intra-abdominal injury and should never be the sole diagnostic test 3

Why Not the Other Organs?

Spleen (Option A) - Less Likely

• While the spleen is the most commonly injured organ in blunt abdominal trauma overall 1, 4, 5, handlebar injuries specifically target the pancreas due to their focal anterior compression mechanism
• Splenic injuries typically cause left upper quadrant pain, not generalized upper abdominal pain
• Splenic trauma usually produces more dramatic hemodynamic instability and significant hemoperitoneum that FAST would detect 4

Liver (Option B) - Less Likely

• Hepatic injuries from handlebar trauma are less common than pancreatic injuries due to anatomic positioning
• Liver injuries typically present with right upper quadrant pain and would likely show free fluid on FAST if significant 2

Urinary Bladder (Option D) - Incorrect

• The bladder is located in the pelvis, not the upper abdomen, making this anatomically inconsistent with the clinical presentation 2
• Handlebar injuries strike the upper abdomen, not the pelvis
• FAST is particularly poor at detecting genitourinary injuries, but the pain location excludes bladder injury regardless 2

Immediate Management Algorithm

Step 1: Obtain Contrast-Enhanced CT Immediately

• CT with IV contrast is the gold standard with 97% sensitivity and 95% specificity for intra-abdominal injuries requiring intervention 3
• CT is specifically superior for detecting pancreatic injuries, which FAST routinely misses 2
• The patient's hemodynamic stability (despite tachycardia) makes them an appropriate candidate for CT imaging 2, 1

Step 2: Consider Advanced Pancreatic Imaging

• If CT shows pancreatic injury, MRCP or ERCP may be necessary to identify pancreatic ductal disruption, which determines management strategy 1
• Ductal integrity assessment is critical, as ductal injuries require different management than simple contusions 1

Step 3: Clinical Pitfall to Avoid

• Do not repeat FAST or rely on serial FAST exams when peritoneal signs are present or mechanism suggests solid organ injury 3
• Do not delay definitive CT imaging based on relatively stable vitals, as pancreatic injuries characteristically have delayed clinical deterioration 1

Key Clinical Pearl

The combination of handlebar mechanism + upper abdominal pain + inconclusive FAST = pancreatic injury until proven otherwise. This injury pattern is a classic teaching case because the pancreas is deeply positioned, injuries don't bleed dramatically initially, and FAST cannot visualize the retroperitoneum adequately 2, 1.