Overview
Definition:
Pancreatitis in children is an acute or chronic inflammatory condition of the pancreas, characterized by enzymatic autodigestion and inflammation
Acute pancreatitis is defined by the sudden onset of abdominal pain with elevated serum amylase and/or lipase levels to at least three times the upper limit of normal, with or without characteristic findings on imaging
Chronic pancreatitis involves irreversible structural damage with loss of exocrine and endocrine function.
Epidemiology:
The incidence of acute pancreatitis in children is increasing, with reported rates varying from 0.2 to 3.2 per 100,000 children
Common etiologies include idiopathic causes, gallstones, trauma, infections (viral, bacterial), medications, and metabolic disorders
Recurrent acute pancreatitis can lead to chronic pancreatitis, affecting approximately 5-10% of affected children.
Clinical Significance:
Pancreatitis in children poses a significant challenge due to its potential for severe morbidity and mortality
Proper management of fluids and nutrition is paramount in reducing systemic complications, supporting organ function, promoting healing, and preventing malnutrition
This is a core area for pediatric residents preparing for board examinations.
Clinical Presentation
Symptoms:
Epigastric abdominal pain, often severe and constant
Pain may radiate to the back
Nausea and vomiting are common
Fever may be present
Abdominal distension
Decreased or absent bowel sounds in severe cases
Jaundice may occur if there is biliary involvement
Signs of dehydration may be present.
Signs:
Tenderness in the epigastrium on palpation
Guarding and rebound tenderness may indicate peritonitis
Tachycardia and hypotension may suggest hypovolemia or sepsis
Tachypnea and hypoxia can occur with respiratory compromise
Cullen's sign (periumbilical ecchymosis) and Grey Turner's sign (flank ecchymosis) are rare but indicative of severe hemorrhagic pancreatitis.
Diagnostic Criteria:
Diagnosis of acute pancreatitis requires at least two of the following three features: 1
Characteristic abdominal pain
2
Serum amylase and/or lipase levels at least three times the upper limit of normal
3
Characteristic findings on cross-sectional imaging (CT scan) or ultrasound.
Diagnostic Approach
History Taking:
Detailed history of onset, character, and radiation of pain
Associated symptoms like nausea, vomiting, fever
Previous episodes of pancreatitis
Family history of pancreatitis or related conditions
Medications, recent trauma, or infections
Dietary habits and recent fatty food intake
History of gallstones or biliary disease
Symptoms suggestive of systemic inflammatory response syndrome (SIRS) or organ dysfunction.
Physical Examination:
Thorough abdominal examination including inspection for distension or masses, auscultation for bowel sounds, percussion for tympany or dullness, and palpation for tenderness, guarding, and rebound tenderness
Assess for signs of dehydration, jaundice, or hypovolemia
Monitor vital signs closely, including heart rate, blood pressure, respiratory rate, and temperature.
Investigations:
Laboratory Tests: Serum amylase and lipase (elevated >3x normal)
Complete blood count (leukocytosis)
Liver function tests (LFTs) to assess for biliary obstruction
Serum electrolytes, BUN, creatinine to assess hydration and renal function
Glucose levels
Calcium levels
Triglycerides (if hypertriglyceridemia is suspected)
Lactate dehydrogenase (LDH)
C-reactive protein (CRP) as an inflammatory marker
Imaging: Abdominal ultrasound to assess pancreas, gallbladder, and bile ducts for stones or dilation
Contrast-enhanced computed tomography (CECT) of the abdomen is the gold standard for assessing severity and complications like necrosis or pseudocysts
Magnetic resonance cholangiopancreatography (MRCP) for detailed evaluation of the biliary and pancreatic ducts
Interpretation: Elevated amylase/lipase confirms pancreatic involvement
CT scan is crucial for staging and severity assessment (e.g., Balthazar score).
Differential Diagnosis:
Other causes of acute abdominal pain: Appendicitis
Cholecystitis
Bowel obstruction
Perforated viscus
Mesenteric ischemia
Gastroenteritis
Urinary tract infection
Pneumonia (referred pain)
Diabetic ketoacidosis
Inborn errors of metabolism.
Management
Initial Management:
Fluid resuscitation: Aggressive intravenous fluid therapy is critical
Isotonic crystalloids (e.g., Lactated Ringer's solution or 0.9% normal saline) at a rate of 5-10 mL/kg/hour, aiming for adequate urine output (>1 mL/kg/hour) and resolving hypovolemia
Pain control: Opioids (e.g., morphine, hydromorphone) via continuous infusion or patient-controlled analgesia (PCA)
Antiemetics for nausea and vomiting
Nasogastric (NG) tube placement for gastric decompression if significant vomiting or ileus is present.
Medical Management:
Nutritional support is paramount
Early enteral nutrition is preferred over parenteral nutrition whenever possible, as it helps maintain gut integrity and reduces the risk of infectious complications
Start with clear liquids or semi-liquid diet once pain and vomiting subside, advancing as tolerated
If enteral feeding is not tolerated or feasible within 48-72 hours, initiate parenteral nutrition (PN)
PN formulation should include carbohydrates, amino acids, lipids, vitamins, and minerals, with careful monitoring of glucose, electrolytes, and triglycerides
Specific nutrient requirements should be calculated based on the child's age, weight, and metabolic status
Antibiotics are generally not indicated unless there is evidence of infection (e.g., infected pancreatic necrosis or other documented infection).
Surgical Management:
Surgery is typically reserved for specific complications of pancreatitis
Indications include infected pancreatic necrosis, significant pancreatic abscess, or biliary obstruction unresponsive to conservative management
Surgical options may include drainage procedures (percutaneous or endoscopic) or debridement of necrotic tissue
Laparoscopic cholecystectomy may be considered in children with gallstone pancreatitis once the acute episode has resolved and the patient is stable, but this is generally not an emergency procedure in the acute phase.
Supportive Care:
Close monitoring of vital signs, fluid balance (input/output), electrolytes, glucose, and renal function
Serial abdominal examinations
Respiratory support if indicated (e.g., supplemental oxygen, mechanical ventilation in severe cases)
Management of electrolyte imbalances
Monitoring for signs of SIRS and organ dysfunction
Nursing care should focus on comfort, pain management, and prevention of pressure sores.
Complications
Early Complications:
Systemic inflammatory response syndrome (SIRS)
Acute respiratory distress syndrome (ARDS)
Acute kidney injury (AKI)
Hypovolemic shock
Electrolyte disturbances (hypocalcemia, hypokalemia)
Hemorrhagic pancreatitis
Pancreatic pseudocyst formation
Infected pancreatic necrosis.
Late Complications:
Chronic pancreatitis
Pancreatic insufficiency (exocrine and endocrine)
Diabetes mellitus
Pancreatic pseudocysts requiring intervention
Strictures of the pancreatic duct or biliary tree
Malabsorption
Growth failure in children.
Prevention Strategies:
Prompt recognition and aggressive initial management of fluid resuscitation and pain control
Early initiation of appropriate nutritional support (enteral preferred)
Judicious use of antibiotics only when indicated
Close monitoring for complications and prompt intervention
Identifying and addressing underlying causes of pancreatitis (e.g., genetic factors, metabolic disorders).
Prognosis
Factors Affecting Prognosis:
Severity of pancreatitis (based on imaging and clinical assessment)
Presence and extent of pancreatic necrosis
Development of organ failure
Onset and management of complications
Underlying etiology
Promptness and appropriateness of treatment
Nutritional status of the child.
Outcomes:
Most children with mild acute pancreatitis recover fully with supportive care
Severe pancreatitis with necrosis and organ failure has a higher mortality rate, although improvements in management have reduced this
Recurrent episodes of pancreatitis increase the risk of developing chronic pancreatitis and its long-term sequelae.
Follow Up:
Children with acute pancreatitis should have regular follow-up to monitor for recurrence and potential development of chronic pancreatitis
Those with chronic pancreatitis require long-term management of pain, exocrine insufficiency (enzyme replacement), and endocrine insufficiency (diabetes management)
Nutritional status should be assessed and supported
Imaging may be required periodically to monitor for complications like pseudocysts.
Key Points
Exam Focus:
Aggressive IV fluid resuscitation (5-10 mL/kg/hr crystalloids) is the cornerstone of initial management
Early enteral nutrition is preferred over PN to maintain gut integrity
Identifying common pediatric etiologies is crucial (idiopathic, gallstones, trauma, viral)
Monitor for complications like SIRS, ARDS, AKI, and infected necrosis.
Clinical Pearls:
Don't delay nutrition
initiate enteral feeds as soon as tolerated
If NG tube is in place, feed through it
Be vigilant for signs of dehydration in vomiting children
Hypocalcemia and hypomagnesemia are common and require correction
Consider genetic testing in recurrent or idiopathic pancreatitis.
Common Mistakes:
Inadequate fluid resuscitation leading to hypovolemia and organ dysfunction
Delayed initiation or avoidance of enteral nutrition
Overuse of antibiotics without evidence of infection
Failure to monitor for and manage complications promptly
Misinterpreting abdominal pain in children, leading to delayed diagnosis.