Paediatrics: Pancreatitis

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 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 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 inflam-mation, destruction of pancreatic tissue, and fibrosis, leading to perma-nent 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), pancreozymin-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.