Pocket Pediatrics: The Massachusetts General Hospital for Children Handbook of Pediatrics (Pocket Notebook Series), 2 Ed.

ACUTE PANCREATITIS

Etiologies (J Pediatr Gastroenterol Nutr 2011;52:262)

• Idiopathic (13–34%)

• Trauma (10–40%): Blunt abdominal, postsurgical, post-ERCP

• Biliary tract disease/structural dz (10–30%): Divisum, annular pancreas, choledochal cysts, duct stricture, choledocholithiasis, duplication cyst, sphincter of Oddi dysfunction

• Multisystem disease (14–33%): Sepsis, SLE, HSP, HUS, Crohn’s, Kawasaki

• Drugs/toxins (12–25%): Corticosteroids, VPA, carbamazepine, sulfonamides, metronidazole, pentamidine, tetracycline, furosemide, chlorothiazides, azathioprine, 6-MP, L-asparaginase, scorpion stings, ethanol

• Recent study w/ 25.6% acute pancreatitis 2/2 drugs; most commonly VPA and steroids, L-asp and 6-MP (J Pediatr Gastroenterol Nutr 2011;53:423)

• Infection (10%): Mumps, Coxsackie B, CMV, HAV, VZV, EBV, HBV, Flu A/B, mycoplasma, leptospirosis, ascariasis, malaria

• Hereditary (5–8%) – see Chronic Pancreatitis for etiologies

• Metabolic (2%) → DKA, hyperlipidemia, hypercalcemia, organic acidemia, malnut/refeed

Clinical Presentation (J Pediatr Gastroenterol Nutr 2011;52:262)

• Abd pain (87%), classically epigastric/LUQ radiating to back but <10% in children; worse after eating, N/V (40–80%), anorexia, and altered sensorium

• Exam: abd pain, +/− distention, +/− guarding (29–37%)/rebound, ↓ BS, fever, ↑ HR

• Retroperitoneal hemorrhage (Cullen – periumbilical, Grey Turner – flank)

• Wide spectrum of presentation from normal exam to hypotension and shock

Diagnostic Studies

• Laboratory testing (Am J Gastroenterol 2002;97:1309)

• Amylase: Spec highest when >3× nml limit, rises w/i hrs, no correlation btw rise and severity of dz, 20% false neg, can fractionate pancreatic vs. salivary

• Lipase; spec highest if >3× nml, more spec than Amy, ↑ up to 14 d, 85–95% sens

• Imaging studies

• Abd U/S: W/ pancr enlargement, ↓ echogenicity, dilated ducts, pseudocyst, gallstones. Can be used for guided aspiration of pseudocyst

• CT: W/ diffuse enlarge, +/− hemorrhage, necrosis, pseudocyst. 20% w/ nml CT, rapid bolus better identify necrosis. Used when U/S not adeq to identify anatomy

• MRCP: Can define anatomy for therapeutic intervention but not therapeutic

• ERCP: Indications include recurrent or prolonged pancreatitis, abn MRCP, trauma, sphincterotomy, gallstone extraction. Growing pediatric experience. Most sensitive and specific test for divisum and choledochal cyst, sphincter of Oddi dysfunction

Indicators of Severity (Am J Gastroenterol 2002;97:1726)

• Multiple scoring systems are used in adults (Ranson criteria, Glasgow, APACHE, CT-severity index) but none have been validated in children

• Some widely agreed upon indicators for severe disease include:

• Clinical: Altered sensorium, hypotension, renal failure, pulmonary edema, shock

• Labs: ↓ Ca, ↑ gluc, hypoxemia, ↑ BUN and Cr, ↑ WBC, alb, CRP 48 hr into course

• Imaging: Amount of necrosis correlates w/ risk of infection and severity of disease

Treatment (N Engl J Med 2006;354:2142)

• Classic approach was initial fluid resuscitation, pain management, and bowel rest

• Enteral (NGT) vs. parenteral nut: Recent adult data w/ ↓ in infxn and dz severity w/ enteral feeding. (BMJ 2004;328:1407). PO should begin once pain improved

• Pain mgmt: Meperidine often used over MSO4; no studies show advantage

• NGT decomp: Often used but lack of published evidence (not in mild disease)

• Antibiotic: Use is controversial (some studies show benefit, others do not)

• May be reserved for cases with severe necrotizing disease

• ERCP papillotomy: Diagnostic and therapeutic, indications discussed above

• Surgery: Indicated if infected necrosis (may be confirmed by FNA), trauma w/ duct rupture. Relative indications – sterile necrosis with more than 50% involved

Complications (N Engl J Med 2006;354:2142)

• Systemic: Shock, metabolic derangement (hypoCa, hyperglycemia, hyperK, hyperlipidemia), GI hemorrhage, ileus, stress ulcer, obstruction, colonic wall erosion, splenic hematoma, pericarditis, pleural effusion, ARDS, Δ MS, psychosis, coma, ↓ plts, hemolysis, DIC

• Local:

• Pseudocyst; expanding, organized fluid collection; diagnosed by abd U/S

• Asymptomatic cysts do not require intervention

• Some require drainage (endoscopic, IR, surgical) need 4–6 wk for maturity

• Complications include rupture, hemorrhage, infection

• Necrosis: Diffuse or focal, can develop early in course. Suspected w/ fever, leukocytosis, and failure to improve. Dx by CT (rapid bolus technique)

• Complications: Infected necrosis/abscess (can dx by FNA). Rx w/ abx or surgery



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