Obtain a contrast-enhanced computed tomography (CT) scan as the gold standard for diagnosing pancreaticnecrosis and peripancreatic fluid collections
Obtain a contrast-enhanced computed tomography (CT) scan as the gold standard for diagnosing pancreaticnecrosis and peripancreatic fluid collections: Excerpt from Avoiding Common Pediatric Errors
Author:
Mindy Dickerman, MD
What to Do - Gather Appropriate Data
Acute pancreatitis can be classified as edematous, interstitial pancreatitis
(mild) or necrotizing pancreatitis (severe). Although most attacks of acute
pancreatitis are mild and patients recover relatively quickly, severe necrotizing pancreatitis is associated with a high rate of morbidity and a significant
mortality. Rarely, there are patients who present with early severe acute
pancreatitis, consisting of extensive pancreatic necrosis and organ failure at
admission.
Knowing the severity of pancreatitis helps determine the management
and predicted outcome. Contrast-enhanced CT is the imaging modality of
choice to assess the severity of acute pancreatitis and for detecting complications related to acute pancreatitis. Contrast-enhanced CT distinguishes
between edematous and necrotizing pancreatitis because areas of necrosis
and exudate do not enhance. CT is more accurate than ultrasonography
for the diagnosis of severe pancreatic necrosis. It takes time for pancreatic
necrosis to develop and is unlikely to be seen by contrast CT on the first
day of illness. It is, therefore, more helpful to obtain a contrast CT if the
initial diagnosis is unclear, if a child with acute pancreatitis is deteriorating,
or is determined clinically or by outcome severity score to have severe pancreatitis. A radiologist is able to assign a CT severity index score based on
the percentage of necrosis seen on contrast enhanced CT, which is used to
predict outcome and dictate subsequent management in adults.
If necrosis is present, many adult centers will transfer a patient to the
intensive care unit and initiate antimicrobial therapy with a broad-spectrum
antibiotic such as imipenem. Infected pancreatic necrosis is associated with a
high mortality (up to 80%). Surgical dŽebridement of the pancreas is recommended if a patient is unstable or if there is evidence of infected pancreatic
necrosis that is unresponsive to more conservative management.
Pancreatic injury from blunt trauma, although rare, is an important
cause of pancreatitis and pancreas-related complications. Pancreatic injuries
occur in <3% of children with blunt abdominal trauma. The typical mechanism of injury includes hitting bicycle handlebars, motor vehicle crashes,
and direct blows to the abdomen (as may occur in child abuse). The pancreatic injury is thought to be from compression of the pancreas against the
rigid spinal column or secondary to discrete intrusion forces. Young children, are more likely to sustain pancreatic abdominal injuries from blows
to the abdomen than adults, because they have flatter diaphragms, thinner
abdominal walls, and higher costal margins.
Children with pancreatic injuries due to blunt trauma may present with
symptoms of vomiting or abdominal pain that radiates to the back. On examination, they may have epigastric tenderness that is persistent. Severe
injury can lead to peritonitis and hypovolemia from leakage of pancreatic
enzymes. If presentation is delayed, patients may have epigastric pain, palpable abdominal mass, and elevated amylase levels. It is important to know
that children may or may not have bruising on their abdomen or back in the
setting of significant abdominal organ injury.
Elevated serum amylase may indicate intra-abdominal injury but is not
specific for pancreatic injury and, therefore, it is controversial in the management of children with blunt abdominal injury. The specific level has not
beenshowntocorrelatewithseverityofpancreaticinjuryoninitialevaluation
but is helpful when following serial levels if imaging is inconclusive. In the
setting of abdominal trauma, pancreatic injury should be visualized by CT
with an attempt to diagnose pancreatic ductal injury. Admission CT may not
show pancreatic injuries and will likely not show a complicating pseudocyst.
It is helpful to obtain repeat CT imaging if pancreatic injury is suspected.
Although most patients do well with conservative management after pancreatic injury, those with ductal disruption may benefit from early operative
management. The formation of pseudocyst does occur in a percentage of
children after traumatic pancreatic injury.
Suggested Readings
Jobst MA, Canty TG Sr, Lynch FP. Management of pancreatic injury in pediatric blunt ab
dominal trauma. J Pediatr Surg. 1999;34:818–824.
Mattix KD, Tataria M, Holmes J, et al. Pediatric pancreatic trauma: predictors of nonoperative
management failure and associated outcomes. J Pediatr Surg. 2007;42:340–344.
Mayerle J, Simon P, Lerch MM. Medical treatment of acute pancreatitis. Gastroenterol Clin
North Am. 2004;33:855–869.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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