ACUTE PANCREATITIS

Acute pancreatitis (AP) is unusual in the pediatric patient, can affect all age groups and should be considered in children presenting with acute abdominal complaints Causes are diversely and clinical course less severe. The three most common etiological factors are: trauma, drug-induced, and biliary tract disorders. Other factors to consider are: infections (mumps, ascaris, adenovirus), metabolic (branched-chain organic acidemias), structural defects (anomalous union of pancreatico-biliary ductal system), and hereditary. Blunt abdominal trauma is the leading cause (20-30%)of AP by crushing the fixed organ between the spine. Drugs associated to the development of AP are: steroids, L-asparaginase, valproic acid, acetaminophen (drug withdrawal is treatment of choice). Biliary disorders related to AP are gallstone and choledochal cysts by causing transient ductal obstruction. Most common complaint of children with AP is abdominal pain. Diagnosis is confirmed with elevated amylase/lipase in serum and urine (lipase is more specific since pancreas is major source). Imaging studies of utility are US, CT-Scan and ERCP. The use of ERCP in previously idiopathic cases of AP have increased the yield of diagnosing anomalous pancreatico-biliary junctional defects. Management during early phase is supportive with IV therapy, NG decompression, NPO (to decrease acid stimulation and prevent secretin release), and nutritional (TPN). Surgery is rarely required except complications such as abscess and pseudocyst formation.

Uncommon disorder in childhood. Trauma (compressed injury against spinal column) and biliary tract disorders (choledochal cyst, cholelithiasis) are most common cause of pancreatitis. The most common congenital ductal anomaly leading to pancreatitis is pancreas divisum. Most common complaint is midepigastric abdominal trauma associated with nausea and vomiting. Diagnosis is confirmed with elevated levels of amylase and lipase. Ultrasound is useful to determine degree of edema and presence of pseudocyst formation. Treatment consists of: NPO, NG decompression, decrease acid stimulation (H-2 blockers), aprotinin, glucagon, and anticholinergics. Pain is relieved with meperidine. When pancreatic serum enzymes level return to near normal level patient is started in low-fat diet. Antibiotic prophylaxis use is controversial. Surgery is indicated for: abscess formation and pseudocyst. Pseudocysts are the result of major ductal disruptions or minor lacerations. Observation allows spontaneous resolution in 40-60% of cases. Percutaneous aspiration and catheter drainage is another alternative in management. Follow-up studies permit determine if cavity is decreasing in size. This can be done outpatient teaching parents to irrigate the catheter at home to assure patency. Persistency beyond 6 months may need resectional therapy. Additional option is internal drainage (cyst-gastrostomy, cyst-jejunostomy). Abscess should be drained and debride.

Pancreatic pseudocyst formation is an uncommon complication of pancreatic inflammatory disease (pancreatitis) or trauma in children. More than half cases are caused by blunt abdominal trauma. Ultrasound is the most effective and non-invasive way of diagnosing pancreatic pseudocysts. Acute pseudocysts are managed expectantly for 4-6 wk. until spontaneous resolution occurs. 25-50% will undergo spontaneous resolution. Medical therapy consists of decreasing pancreatic stimulation and giving nutritional support. Rupture is the major complication of conservative management. Chronic pseudocysts (> three mo.) will benefit from prompt operation and internal drainage since resolution is rare. Percutaneous catheter drainage under local anesthesia using Ultrasound or CT guided technique is an appropriate method of first-line therapy for non-resolving (chronic) or enlarging pancreatic pseudocysts. The approach is transgastric or transcutaneous. Those cysts that fail to resolve with percutaneous drainage should go investigation of ductal anatomy to rule out disruption of the main pancreatic duct. The need for further surgery (drainage or resectional) will depend on the status of the duct of Wirsung.