Paediatrics: Pancreatitis

2021-03-04 12:00 AM

This rare disorder consists of acute pancreatic inflammation with variable involvement of local tissues and remote organ systems.

Pancreatitis

Acute pancreatitis

This rare disorder consists of acute pancreatic inflammation with variable involvement of local tissues and remote organ systems.

Causes

  • Blunt abdominal trauma: e.g. road traffic accident.
  • Viral infection: e.g. mumps, hepatitis A, coxsackie B.
  • Multisystem disease: e.g. SLE, Kawasaki disease, haemolytic–uraemic syndrome, IBD, hyperlipidaemia.
  • Drugs and toxins: e.g. thiopurines, metronidazole, cytotoxic drugs.
  • Pancreatic duct obstruction: e.g. cystic fibrosis, choledochal cyst, tumours.

Presentation

Abdominal pain involving the upper central abdomen, radiating to back, chest, or lower abdomen, vomiting, fever, abdominal tenderness.

Severe cases also exhibit:

  • hypotension;
  • abdominal distension;
  • Cullen’s or Grey–Turner’s sign (bruising of peri-umbilical area and flanks, respectively);
  • ascites;
  • pleural effusion;
  • jaundice;
  • multi-organ failure.

Investigations

  • Blood: amylase (ii); lipase (i); Ca2+(d); ESR/CRP (i); deranged LFT.
  • Radiology: abdominal US or CT; endoscopic retrograde cholangiopancreatography (ERCP) if structural or obstructive cause.

Treatment

Mild

  • Supportive only, e.g. NGT, analgesia.
  • Start short period of nil by mouth to ‘rest’ pancreas.

Severe

Treat as for the mild form, plus:

  • Admit to the intensive care unit.
  • Correct hypotension.
  • Treat multi-organ failure.
  • Surgery if significant pancreatic necrosis, major ductal rupture (trauma), gallstones (cholecystectomy), presence of pseudocyst.
  • Endoscopy (ERCP) may be therapeutic if structural obstructive cause.

Prognosis

  • Complete recovery is likely if there is minimal organ dysfunction.
  • 20% mortality if there is a severe disease or organ failure present, or if local complications develop (e.g. pancreatic pseudocyst).
  • Most children have only a single acute episode.

Chronic pancreatitis

This very rare condition follows acute pancreatitis with continuing inflammation, destruction of pancreatic tissue, and fibrosis, leading to permanent exocrine or endocrine pancreatic failure. It is usually caused by cystic fibrosis, congenital ductal anomalies, sclerosing cholangitis (IBD), hyper-lipidaemia, or hypercalcaemia.

Presentation

  • Repeated episodes of acute pancreatitis are separated by good health.
  • Eventually, features of pancreatic exocrine failure or diabetes mellitus become apparent.

Investigations

  • Abdominal US or CT scan confirms chronic pancreatitis.
  • Pancreatic function tests may be useful, e.g. stool chymotrypsin (i), pancreozymins-secretin test, 72hr faecal fat measurement (i).

Treatment

  • Treat acute exacerbations as for acute pancreatitis.
  • Give pancreatic enzyme replacement and nutritional supplementation (well-balanced diet with moderated fat intake and fat-soluble vitamins—involve a paediatric dietician).
  • Relieve any ductal obstruction by endoscopy or surgery.

Prognosis

Recovery or risk of developing long-term pancreatic exocrine and/or endocrine failure is dependent on cause and severity.