Pediatric Pancreatitis and Pancreatic Pseudocyst Treatment & Management

The goal of medical management of acute pancreatitis is to achieve adequate rehydration, analgesia, and pancreatic rest and to restore normal metabolic homeostasis. In patients with severe pancreatitis, oral intake is restricted and parenteral nutrition is initiated within 3 days to prevent catabolism. In cases of intractable vomiting or ileus, nasogastric suction is indicated to help intestinal-pancreatic rest by eliminating gastric secretions in the duodenum, the most potent activator of pancreatic secretion. Fluid electrolyte and mineral imbalances should be corrected urgently. Antibiotic therapy is indicated for systemic infections or sepsis. Acute pancreatitis should resolve in 2-7 days with adequate resuscitation. In the setting of chronic relapsing pancreatitis, pancreatic enzyme supplementation, insulin, and elemental or low-fat diets are useful adjuncts to maximize nutritional status. For alleviation of pain, meperidine is preferred over morphine because of its decreased risk of ampullary spasm.

Surgical management of acute pancreatitis is rarely required. Surgical intervention is only needed if the symptoms are severe and prolonged or complicated by necrosis or abscess formation that requires debridement. Peritoneal lavage has been used in adults in an effort to reduce the incidence of secondary infection; however, this has not been through trials with children to test its efficacy. If underlying pancreaticobiliary disease is present, surgical intervention is required for cure. Most surgical interventions are used in patients with chronic or relapsing pancreatitis. The goal of surgery in this instance is to alleviate pain and preserve the exocrine and endocrine functions of the pancreas. Surgical therapies include longitudinal pancreaticojejunostomy, distal pancreatectomy with Roux-en-Y pancreaticojejunostomy, decompression of pancreatic ducts, repair of pancreatic divisum, and sphincteroplasty.

Surgery for pancreatic ductal disruption or compromise (ie, acute traumatic pancreatitis with ductal injury) is indicated after medical failure. Endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative pancreatic ductography is essential to identify the ductal disruption, and findings direct definitive surgical therapy.

Acute pancreatic pseudocysts smaller than 5 cm in diameter are managed with observation for 4-6 weeks because most resolve spontaneously. Pancreatic pseudocysts larger than 5 cm in diameter may require surgical intervention; however, conservative therapy is required for approximately 4-6 weeks to allow the cyst wall to mature. Results from a study by Ford et al indicate that pancreatic pseudocysts larger than 10 cm in diameter in children are associated with increased risk for spontaneous rupture and, thus, require aggressive monitoring.^[8]

Chronic pancreatic pseudocysts (>3 mo duration) are best treated by surgical interventions. Ultrasonography-guided or CT-guided percutaneous drainage, endoscopic drainage, and internal drainage have been used with success. Surgical approaches for internal drainage are largely determined by the anatomic location of the pseudocyst. If the pseudocyst is adherent to the posterior wall of the stomach, cystogastrostomy is performed. If the cyst is present in the head of the pancreas, cystoduodenostomy is considered. For other cysts not adherent to the stomach or duodenum, cystojejunostomy is preferred. Distal pancreatectomy is considered when the pseudocyst is in the tail of the gland.

Managing pancreatic pseudocysts with endoscopic treatment has been an increasing trend. Recent evidence has demonstrated that, in skilled hands, endoscopic treatment is safe and effective (for short-term and long-term treatment). Some authors suggest that endoscopic treatment should be the first choice. Success rate is as high as 85%. Surgical treatment can be reserved for those cases that fail endoscopic treatment.

Preoperative studies with ultrasonography and CT scanning, the preferred imaging modalities used to diagnosis and follow the course of pancreatitis and pancreatic pseudocysts, are important to assess the character and size of the pseudocyst. ERCP is essential to assess various ductal abnormalities or pseudocyst communication with the pancreatic duct to determine definitive operative therapy.

Although pseudocyst formation is an uncommon sequela of acute or chronic pancreatitis in children, complications of pancreatic pseudocysts include spontaneous rupture, hemorrhage, and infection. Pseudocysts can be medically managed with pancreatic rest or surgically by internal or external drainage. While under medical therapy, rupture is the major complication associated with pseudocysts larger than 10 cm.

Cases of uncomplicated acute pancreatitis usually resolve within 2-4 days. The management of acute pancreatitis is predominately supportive medical therapy, with intravenous hydration, pain control, and bowel rest. Parenteral nutrition may be required for prolonged episodes. Diagnosis of the specific cause of pancreatitis is important to elucidate, as there is a 9% recurrence rate, most of which are diagnosed with idiopathic recurrent pancreatitis or structural anomalies.

The most frequent cause of acute pancreatitis in pediatrics is related to medication administration. If a medication is suspected, it should be stopped immediately and other alternatives should be investigated. Etiologies related to trauma, systemic disease, or anatomic variants are important to determine and direct further medical or surgical interventions. Surgical management is used to address complications of pancreatitis, including hemorrhage, necrosis, ductal fistulae, and pseudocysts.

Surgical management of pancreatic pseudocysts is highly successful. Recurrence rates and mortality rates are low. Internal drainage is associated with lower recurrence rates compared to percutaneous or endoscopic drainage. Transendoscopic and percutaneous drainage of pancreatic pseudocysts have been predominately performed in the adult population, and further investigation and comparison of these techniques in children is warranted to determine the optimal management of this disease.

The use of total pancreatectomy with islet cell transplantation is undergoing evaluation for the treatment of chronic abdominal pain in children with chronic pancreatitis.