Acute Pancreatitis

Acute pancreatitis can be serious, resulting in life-threatening complications (e.g., multiple organ failure). Most cases of pancreatitis are mild, and children will recover without complications. However, early in the course of pancreatitis, it is difficult to determine who will progress to have severe disease, making early identification and close monitoring important.

The estimated incidence of acute pancreatitis in children is 13 cases per 100,000 children annually and appears to be increasing, approaching the incidence in adults. The reasons for the increase are not clear and may only partially be explained by increased awareness.

Etiology: Unlike older patients, in whom the primary risk factors for acute pancreatitis are related to obstructive biliary disease and alcohol consumption, no etiology predominates in pediatric patients. After idiopathic etiologies, drug-induced pancreatitis is the most common of known risk factors for acute pancreatitis in pediatric patients.

Presentation: The most common presenting symptoms of acute pancreatitis in children are as follows:

• abdominal pain

• irritability

• diffuse abdominal tenderness

• nausea

• emesis

• anorexia

• fever

Diagnosis

Diagnostic criteria: In 2018, the International Study Group of Pediatric Pancreatitis: In search for a cure (INSPPIRE) consortium published a consensus statement on the definition and diagnosis of pancreatitis in children. These guidelines define pediatric acute pancreatitis as at least two of the following three presenting criteria:

• abdominal pain compatible with acute pancreatitis: acute onset, especially in the epigastric region

• serum lipase and/or amylase values three times the upper limits of normal

• imaging findings consistent with acute pancreatitis: edema, necrosis, inflammation, abscess, or pseudocyst

Blood tests: During the initial evaluation of acute pancreatitis in children, blood tests should include:

• complete blood count

• chemistry panel (including electrolytes, blood urea nitrogen [BUN], creatinine, and glucose)

• serum amylase and lipase

• measures of liver status (aspartate aminotransferase [AST], alanine aminotransferase [ALT], gamma glutamyl transpeptidase [GGTP], alkaline phosphatase, and total and direct bilirubin)

• triglyceride levels

• serum calcium

Other laboratory tests:

• urine specific gravity: may aid in evaluating hydration and intravascular volume status

• erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): may aid in determining the level of systemic inflammation

Imaging: Although initial imaging of the abdomen with ultrasound may be warranted to identify obstructive etiologies and to gauge the extent of pancreatic inflammation, computed tomography (CT) and magnetic resonance imaging (MRI) may help characterize cysts or pseudocysts and assess for signs of pancreatic necrosis.

Note: The INSPPIRE group consensus statement highlights the following two important observations regarding the presentation of acute pancreatitis in children:

• Pain secondary to acute pancreatitis may be vague, nonspecific, and nonradiating in children.

• The correlation between serum lipase or amylase levels and severity of disease is generally poor in children. As such, these biochemical parameters should not be used to track disease severity or response to treatment.

Mild versus severe disease: Most cases of acute pancreatitis in children are mild. Severe disease (defined as pancreatitis leading to multi-organ dysfunction, pancreatic necrosis, or death) is uncommon, yet typical adult prognostic tools such as the Ranson criteria are not easily applicable to young children. Developing such a tool is a priority in pediatric pancreatology.

Medical Management

Guidelines for the management of pediatric acute pancreatitis have been published by the Pancreas Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). The overall goal of management is to recognize intravascular hypovolemia and treat it aggressively, monitor for signs of vital organ dysfunction, treat pain, and identify reversible causes. Early fluid resuscitation may prevent pancreatitis from progressing.

• Principles of initial fluid resuscitation:

  • If patients present with signs or symptoms consistent with clinical dehydration or hemodynamic compromise, consider administration of a bolus of 10 to 20 mL/kg of lactated Ringer solution or normal saline.

  • Provide 1.5 to 2.0 times maintenance intravenous (IV) fluids, with close monitoring of urine output, during the first 24 to 48 hours.

  • Children with mild acute pancreatitis may benefit from early oral or enteral (nasogastric, nasoduodenal, or nasojejunal tube) feeding.

  • Parenteral nutrition should be considered for patients with moderate-to-severe pancreatitis when enteral nutrition cannot be initiated for more than 5 to 7 days but should be combined with enteral nutrition when possible.

• Monitor for vital organ dysfunction: The initial 48-hour period after presentation is critical and requires the following:

  • Closely monitor and track cardiac, respiratory, and renal status.

  • Check vital signs at least every 3 hours in patients with mild-to-moderate disease severity on the general inpatient floor, or continuously in patients with moderate-to-severe disease in the intensive care unit (ICU).

  • Administer fluid resuscitation if indicated at presentation and adjust ongoing IV hydration to maintain a target urine output of 0.5 to 1.0 mL/kg per hour.

  • Closely monitor serial BUN and creatinine values for signs of acute or evolving kidney injury.

  • Control pain with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), or consider IV morphine or other opioids for pain associated with acute pancreatitis

  • Empiric antibiotics are not recommended unless a patient has suspected infected necrotic pancreatitis.

• Identify reversible causes, including anatomical problems (e.g., congenital anomaly causing pancreatic duct obstruction), an obstructing stone, or recognizing and treating a metabolic defect (e.g., hypertriglyceridemia or hypercalcemia)

  • Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in the management of choledocholithiasis-induced biliary pancreatitis, pancreatic ductal stones, ductal leaks, or stricture associated with pancreatitis.

  • Surgical consult should be considered if choledocholithiasis is identified, because cholecystectomy can be performed safely during the index hospitalization and reduce the risk for subsequent episodes of gallstone pancreatitis.

• Intensive monitoring is recommended in the following patients:

  • those requiring more than two boluses of 20 mL/kg of isotonic fluids (because of concern for ongoing third spacing)

  • those with prior ICU admissions for pancreatitis

  • patients who are nonverbal, cannot convey pain, have mental status changes, or have behavioral comorbidities (because it may be harder to identify illness progression)

Acute Recurrent Pancreatitis

Acute recurrent pancreatitis (ARP) is defined as two or more episodes of pancreatitis with interval resolution of pain or pancreatic enzyme levels. Patients with ARP may benefit from additional evaluation including:

• specialized imaging such as magnetic resonance cholangiopancreatography (MRCP) to identify any anatomic or congenital causes predisposing to pancreatitis

• sweat chloride testing

• genetic testing for mutations in genes that have been shown to predispose to pancreatitis (e.g., CFTR, SPINK1, PRSS1, CTRC, and CaSR)

• follow-up after discharge with a pediatric gastroenterologist, preferably a pancreatic disease specialist, to help determine appropriate diagnostic tests