Pancreatitis
Pancreatitis: Excerpt from The 5-Minute Pediatric Consult
Raman Sreedharan, MDDevendra I. Mehta, MD
Pancreatitis - BASICS
Pancreatitis - description
Inflammation of the pancreas characterized by variable local and systemic inflammatory responses. Classified into acute and chronic:
- Acute:
- Characterized by abdominal pain, nausea, and vomiting with elevation of pancreatic enzymes
- Usually self-limiting
- Recurrent episodes of pancreatitis may occur, but the pancreatic function and morphology are restored between episodes.
- Severe acute pancreatitis is rare in children and has a high mortality.
- Chronic:
- Characterized by recurrent or persistent abdominal pain with morphologic changes in the pancreas, leading to pancreatic exocrine or endocrine insufficiency in some patients.
Pancreatitis - etiology
- Idiopathic (20–25%)
- Trauma:
- Bicycle handle injuries
- Motor vehicle collisions
- Child abuse
- Postoperative:
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Scoliosis surgery
- Transplantation
- Infections:
- Bacterial:
- Viral: Measles, mumps, Epstein-Barr virus, Coxsackie B, rubella, influenza, echovirus, hepatitis A and B
- Parasites (Ascaris lumbricoides, Echinococcus granulosus, Cryptosporidium parvum, Plasmodium falciparum)
- Biliary tract disease:
- Gallstones
- Sclerosing cholangitis
- Congenital anomalies:
- Pancreatic divisum
- Annular pancreas
- Anomalous choledochopancreaticoduodenal junction
- Biliary tract malformations
- Duplication cyst of the duodenum/gastropancreatic/common bile duct
- Metabolic:
- Hyperlipidemia
- Hypercalcemia
- Uremia
- Inborn errors of metabolism
- Systemic disease:
- Shock/Hypoxemia
- Hemolytic uremic syndrome
- Crohn disease
- Celiac disease
- Malnutrition: Anorexia nervosa, bulimia, and refeeding syndrome
- Diabetes mellitus
- Mitochondropathy
- Hemochromatosis
- Vasculitis: Systemic lupus erythematosus (SLE), Henoch-Schönlein purpura, Kawasaki disease
- Drugs: L-asparaginase, azathioprine/6-MP, mesalamine, sulfonamides, thiazides, furosemide, tetracyclines, valproic acid, corticosteroids, estrogens, procainamide, ethacrynic acid, and others
- Toxins:
- Alcohol, organophosphates, scorpion poison, snake poison
- Hereditary:
- Cystic fibrosis: CFTR mutations
Pancreatitis - DIAGNOSIS
Pancreatitis - signs & symptoms
- Upper abdominal pain:
- Usually epigastric with radiation to the back
- May have some relief of pain on stooping forward
- Aggravated by food intake
- Fever:
- Low-grade fever
- High-grade fever is usually due to infection.
- Nausea and vomiting common:
Pancreatitis - history
- Trauma:
- Even trivial abdominal trauma should be a red flag
- Evaluate for evidence of child abuse.
- Family history:
Pancreatitis - physical exam
- General examination:
- Growth parameters (weight and height), vital signs, capillary refill, pulse oximetry, pallor, jaundice, edema and clubbing
- Pallor could be due to chronic systemic disease or hemorrhage.
- Clubbing could be an indicator of cystic fibrosis.
- GI:
- Mouth: Presence of aphthous ulcers: Possibility of Crohn disease
- Inspection: Abdominal distention or flank fullness (ascites or pseudopancreatic cyst); bluish discoloration of the flanks (Grey Turner sign) and periumbilical region (Cullen sign) in hemorrhagic pancreatitis.
- Palpation: Guarding, tenderness and rebound tenderness, especially in the epigastric region or upper abdomen; palpable mass could be a pancreatic pseudocyst; palpate for liver, gall bladder, spleen, and other masses.
- Percussion: Dullness and fluid thrill in ascites
- Auscultation: Bowel sounds decreased in ascites or absent in paralytic ileus
- Rectal examination: Perianal region for skin tags, fistulas, abscesses, or healed scars, which could be indicative of inflammatory bowel disease; per-rectal examination for mass, melena or occult blood
- Respiratory system:
- Pleural effusion and acute respiratory distress syndrome (ARDS)
- Diffuse respiratory findings could be indicative of cystic fibrosis.
- CNS:
Pancreatitis - tests
Pancreatitis - lab
- CBC:
- Hemoglobin may be decreased in hemorrhagic pancreatitis or in intestinal hemorrhage.
- Hemoconcentration occur in shock states.
- Basic metabolic panel:
- Electrolyte imbalance due to fluid shift and renal complications
- Calcium is decreased.
- Glucose may be transiently elevated.
- Liver function tests:
- Elevated transaminase levels
- Elevated bilirubin level
- Amylase level:
- 3-fold elevation in the level increases the specificity for the diagnosis of pancreatitis.
- Starts rising 2–12 hours after the insult and remains elevated for 3–5 days.
- Persistent elevation could be due to complication such as pseudocyst.
- Degree of elevation does not have any correlation to the severity or the course of the illness.
- Necrotizing and hemorrhagic pancreatitis may develop with normal amylase levels.
- Other causes of elevated amylase levels include bowel obstruction, acute appendicitis, biliary obstruction, salivary duct obstruction, diabetic ketoacidosis, cystic fibrosis, pneumonia, salpingitis, ruptured ectopic pregnancy, ovarian cyst, cerebral trauma, burns, renal failure and macroamylasemia.
- Lipase level:
- Lipase levels are more specific than amylase for the diagnosis of pancreatitis.
- Starts rising 4–8 hours after the insult and remains elevated for 8–14 days.
- 3-fold increase in the level is very sensitive and specific for pancreatitis.
- Levels do not correlate with severity or with clinical outcome.
- Other causes of elevated lipase levels include intestinal perforation, intestinal obstruction, appendicitis, mesenteric infarction, cholecystitis, diabetic ketoacidosis, renal failure and macrolipasemia.
Pancreatitis - imaging
- Abdominal x-rays:
- Sentinel loop: Distended small intestinal loop near the pancreas
- Colon cutoff sign: Absence of gas shadow in the colon distal to the transverse colon
- Multiple fluid levels in paralytic ileus
- Calcification or stones in pancreas or gallbladder
- Diffuse haziness: Ascites
- Upper gastrointestinal series
- “Reverse 3 sign”/Frostberg sign: The curves of the “3” indicate swelling of the pancreas and the middle apex of the “3” suggests the origin of the duct.
- Anterior displacement of the stomach is seen in pseudopancreatic cyst or retroperitoneal swelling.
- Barium enema: Rarely indicated
- Chest x-ray:
- Pleural effusion or ARDS
- Diaphragmatic involvement
- Ultrasound abdomen:
- Pancreatic size, echogenicity, calcification, stones, abscess and pseudocysts.
- Endoscopic ultrasound is more useful than the transabdominal ultrasound study but is difficult in children.
- CT scan:
- In acute cases as in trauma, to look at extent of injury to pancreas and other intra-abdominal structures.
- Can show complications such as abscess, hemorrhage, pseudocyst, etc.
- Reveals pathology in the pancreaticobiliary system in most instances.
- Magnetic resonance cholangiopancreatography (MRCP):
- More popular than CT scan for identifying pancreaticobiliary disorders.
- Useful for delineation of the ductal structure of the pancreas and also to identify pathology in the hepatobiliary system
- Serotonin stimulated MRCP (sMRCP) is becoming more popular in adults as it delineates the pancreatic ducts better.
- Endoscopic retrograde cholangiopancreatography (ERCP):
- Indicated in persistent/chronic pancreatitis for delineation of pancreatic ducts and for therapeutic interventions.
- Limitations include postprocedure complications and accessibility to gastroenterologist experienced with ERCP in children.
Pancreatitis - TREATMENT
- NPO for pancreatic rest.
- In moderate to severe cases of pancreatitis and in cases with vomiting, nasogastric decompression by placement of nasogastric (NG) tube:
- Acid suppression with H
Pancreatitis - general measures
Pancreatitis - diet
- NPO initially.
- Mild cases may be started on a low-fat diet after a few days.
- Nasojejunal feeds worth considering when oral feeding is not possible even after the 1st few days.
- Alternative is total parenteral nutrition (TPN).
Pancreatitis - special therapy
Pancreatitis - iv fluids
Fluid management:
- Very critical for preventing complications
- Need X1.5 maintenance initially because there is extreme 3rd spacing.
Pancreatitis - medication
- Antibiotics:
- Prophylaxis in severe cases when necrotizing pancreatitis is suspected
- Few antimicrobials, such as imipenem–cilastatin, get adequate penetration.
- Pain management:
- Narcotics
- Meperidine is preferable to morphine because it has less effect on the sphincter of Oddi.
- HPrevents pancreatic stimulation in severe cases
Pancreatitis - surgery
- Peritoneal lavage rarely for salvage in necrotizing/hemorrhagic pancreatitis
- Management of pancreatic abscess and in some cases of pseudocysts.
Pancreatitis - FOLLOW UP
Pancreatitis - prognosis
Acute pancreatitis is usually a self limiting disorder in children.
Pancreatitis - complications
- Pancreatc edema
- Peripancreatic fat necrosis
- Pancreatic phlegmon
- Pancreatic abscess
- Pancreatic pseudocyst
- Hemorrhagic pancreatitis
- Necrotizing pancreatitis
- Pancreatic calculi
- Pancreatic fistula
- Pancreatic ductal strictures
- Pnacreatic ductal dilatation
- Systemic complications
- Shock and multiorgan failure
- GI and hepatobiliary:
- Paralytic ileus
- Ascites, peritonitis
- Stress ulcer
- Intestinal hemorrhage
- Portal vein thrombosis/splenic vein thrombosis/obstruction
- Bile duct obstruction
- Pulmonary:
- Atelectasis, pleural effusion, pneumonitis, ARDS
- Cardiovascular:
- Hypotension/Circulatory collapse
- Pericarditis/Pericardial effusion
- EKG changes
- Sudden death
- Hematologic:
- Hemoconcentration
- Disseminated intravascular coagulation
- Renal:
- Oliguria, azotemia, and renal failure
- Hepatorenal syndrome
- Neurologic:
- Acidosis, hypercalcemia, hyperglycemia, hypertriglyceridemia, hypocalcemia
Pancreatitis - bibliography
- Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute pancreatitis: Value of CT in establishing prognosis. Radiology. 1990;174(2):331–336.
- DeBanto JR, Goday PS, Pedroso MR, et al. Acute pancreatitis in children. Am J Gastroenterol. 2002;97:1726.
- Jackson WD. Pancreatitis: Etiology, diagnosis and management. Curr Opin Pediatr. 2001;13:447–451.
- Pietzak MM, Thomas DW. Pancreatitis in childhood. Pediatr Rev. 2000;21(12).
- Somogyi L, Martin SP, Venkatesan T, et al. Recurrent acute pancreatitis: An algorithmic approach to identification and elimination of inciting factors. Gastroenterology. 2001;120:708–717.
- Whitcomb DC: Clinical practice. Acute pancreatitis. N Engl J Med. 2006;354(20):2142–2150.
Pancreatitis - CODES
Pancreatitis - icd9
- 577.0 Pancreatitis
- 577.0 acute (edematous) (hemorrhagic) (recurrent)
Pancreatitis - FAQ
- Q: What is hereditary pancreatitis?
- A: Hereditary pancreatitis presents as recurrent inflammation of the pancreas and runs in families over 2 or more generations. It is inherited as an autosomal dominant trait with variable penetrance.
- Q: What are the genes associated with pancreatitis?
- A: Mutations of CFTR gene, cationic trypsinogen gene (PRSS1) and Seriene protease inhibitor Kazal type 1 gene (SPINK1) are associated with pancreatitis.
- Q: Can pancreatitis be a presenting symptom for cystic fibrosis?
- A: Yes.
- Q: Do normal findings on an ultrasound or CT scan of pancreas exclude a diagnosis of acute pancreatitis?
- A: No. Normal ultrasound and CT findings are common in mild cases.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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