PaedSurg.Net

Acute pancreatitis, according to the INSPPIRE criteria, is defined as including two of the following

• abdominal pain consistent with acute pancreatitis

• imaging consistent with acute pancreatitis 

• lipase or amylase greater than or equal to three times the upper limit of normal

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In children, the most common causes of acute pancreatitis are trauma, choledocholithiasis (obesity, hemolyticstones, spherocytosis alpha-thalassemia, sickle cell disease, parenteral nutrition), congenital structural abnormalities of the pancreatic and/or biliary system (annular pancreas, pancreatic divisum, stenosis of the ampulla of Vater, pancreaticobiliary malunion, hypertensive sphincter of Oddi choledochal cyst), systemic illness, drugs (valproic acid, l-asparaginase, prednisonepentamidine, metronidazole, macrodantin azathioprine, tetracycline), toxins or idiopathic. 

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TCS-TDS

T - Trauma

C - Choledocolithiasis 

S - Structural abnormalities 

T - Toxins 

D - Drugs 

S - Systemic Illness

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An annular pancreas is caused by abnormal development of the pancreas in which the pancreas encircles the second portion of the duodenum. Annular pancreas may present with a variety of symptoms including duodenal obstruction in the newborn. Pancreatitis, nausea, vomiting,

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Pancreatic divisum is an anomaly in which the pancreatic ducts do not fuse and instead remain as two separate ducts with a majority of the pancreatic secretions draining from the minor papilla.

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Pancreaticobiliary malunion is a condition in which there is a common channel between the pancreatic and biliary ducts above the duodenal wall. This channel may become clogged with stones or plugs causing obstruction and a dilated common channel, resulting in pancreatitis and sometimes jaundice. This common channel can usually be identified on endoscopic retrograde cholangiopancreatogrpahy

 

 

 

 

 

 

 

 

 

 

 

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Modified criteria for children have been published with three or more of the following eight criteria predicting a more severe outcome. 

• At admission

  • age less than seven years

  • weight less than 23 kg

  • admission white blood cell count greater than 18.5 K/μL

  • admission lactate dehydrogenase greater than 2000

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7231852000

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• At 48 hours

  • trough calcium level less than 8.3 mg/dl

  • trough albumin less than 2.6 g/dL

  • fluid sequestration greater than 75 mL/kg/48 hr

  • rise in blood urea nitrogen greater than 5 mg/dL

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CA-A-F-BUN

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Patients with pancreatitis have various presentations.

Patients often report abdominal pain, which may be midepigastric, periumbilical, upper abdominal or diffuse. The pain may radiate to the back or flanks. It is described as constant, cramping or colicky. Associated symptoms may include nausea, vomiting, anorexia, weight loss or diarrhea.

It is important to ask if patient has had any:

• recent trauma or surgery

• recent infections or sick contacts

• new medications or toxin exposure?

• previous episodes

• personal history of blood disorders

• family history of medical problems involving abdominal pain, surgery or pancreas

• family history of calcium problems, cystic fibrosis or elevated triglycerides

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Patients may have abdominal discoloration at the umbilicus (i.e. Cullen sign) or flank (i.e. Grey Turner sign) due to internal bleeding.

Depending on the associated systemic response, patients may have shortness of breath from cytokine release resulting in pulmonary edema or pleural effusions. 

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Investigations 

1. The key laboratory tests for the diagnosis of pancreatitis are serum amylase and lipase. Amylase has a shorter half life and will initially rise more quickly than lipase. Amylase will also normalize sooner than lipase, and thus up to 20% of patients may have a normal amylase by the time they present to medical attention. The amylase may also be elevated due to other problems such as a salivary gland obstruction, cholecystitis, gastroenteritis, renal disease, tumors and medications.

2. A complete blood count and electrolytes are important to assess the clinical status and determine resuscitation needs. Specifically, hemoglobin, white blood cell count, lactate dehydrogenase, blood urea nitrogen, albumin, glucose and calcium levels can be used to assess the severity of pancreatitis. Measurement of these levels at admission and 48 hours later can help monitor the patient’s progress.

3. Serum triglycerides should be checked to identify those patients whose pancreatitis may be due to hyperlipidemia. Liver function tests should be measured to assess for biliary obstruction.

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​​Treatment plan​

​Antibiotics are useful in infected pancreatic necrosis. However, no clear criteria have been identified to clearly distinguish infected from sterile pancreatic necrosis. Evidence of pancreatic necrosis particularly (e.g. gas on CT) are concerning for infected pancreatitis

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Surgery is rarely needed to manage complications​

Infected pancreatic necrosis - controlling of source - 

1. start with antibiotics, 

2. drains may be placed to obtain source control; drains are removed once there is minimal output. If needed, multiple drains may be placed at once or over multiple days, weeks or months. 

3. If the patient does not respond sufficiently, debridement may be necessary. Ideally one would prefer to wait a month or more to allow the pancreatic tissue to demarcate and mature with liquefaction of the internal contents. 

4. If the patient does not respond to the treatment mentioned above or if they have rapid clinical deterioration or uncontrolled sepsis, an open debridement and necrosectomy may be necessary.

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Ductal obstruction 

ERCP with clearance of stones/protein plugs, or stenting of ductal disruption, may expedite pancreatic fluid drainage in children with a pancreatic ductal obstruction.

 

Gallstones 

If the pancreatitis is from gallstones, once the abdominal pain has resolved, the gallbladder should be removed prior to discharge from the hospital

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