Pediatric Pancreatitis and Pancreatic Pseudocyst Workup

  • Author: Andre Hebra, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Oct 21, 2009
 

Laboratory Studies

  • If pancreatitis is suspected, amylase and lipase levels should be measured, as they may support a clinical diagnosis. However, these laboratory test findings alone are not reliable or cost effective as a screening tool, and the magnitude of enzyme elevation does not correlate with the severity of pancreatic injury.[7]
    • Elevated serum or urine amylase levels aid in the diagnosis of pancreatitis and peak 48 hours after onset. Serum amylase levels are typically elevated for as long as 4 days. Amylase levels have been found to be within the reference range in 10-15% of patients with pancreatitis. Amylase levels can be elevated in patients with other abdominal conditions, but typically, they are not as high as levels found in patients with pancreatitis.
    • Serum lipase is more specific than amylase for acute pancreatitis, and typically, lipase levels remain elevated 8-14 days longer than amylase levels. Serum lipase levels can also be elevated in patients with other diseases or conditions; therefore, all laboratory results should be evaluated in the context of the clinical presentation.
  • Other laboratory abnormalities found in patients with pancreatitis may include coagulopathies, leukocytosis, hyperglycemia, glucosuria, hypocalcemia, hyperbilirubinemia, and elevated gamma glutamyl transpeptidase.
  • Urinary levels of trypsin activator peptide (TAP) may help determine the severity of the pancreatitis.
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Imaging Studies

  • Ultrasonography and CT scanning are the preferred imaging modalities used to diagnose and follow the course of pancreatitis and pancreatic pseudocysts. Ultrasonography is the primary screening tool for evaluation of the pediatric pancreas, due to the absence of ionizing radiation and ability to image without sedation. CT scanning may be better suited for evaluation of chronic pancreatitis and its complications, pancreatic trauma, and neoplastic conditions and is often used to further evaluate abnormalities found on ultrasonography.
    • Ultrasonography findings may include a focally or diffusely enlarged, hypoechoic, sonolucent, or edematous pancreas; dilated pancreatic ducts; a pancreatic mass; a fluid collection or peripancreatic fluid; an abscess; or a pseudocyst demonstrated as a well-defined, hypoechoic mass, which may be multilocular.
    • CT scan findings include an enlarged gland with ill-defined margins; peripancreatic fluid; areas of decreased or enhanced density; or pseudocysts with a well-defined wall or capsule and central area of low attenuation. CT scanning is a better modality for evaluating presence and extent of pancreatic necrosis and inflammation of peripancreatic fat.
    • Of note, findings on imaging studies initially appear normal in 20% of children with acute pancreatitis.
  • MRI is another modality to diagnose pancreatitis and is used for the same indications as CT scanning.
  • Endoscopic retrograde cholangiopancreatography (ERCP) is essential for evaluation of pancreatic and biliary anomalies. ERCP can aid in the diagnosis of various ductal abnormalities or obstructions and may serve as a therapeutic intervention (ie, sphincterotomy, stent placement).
  • Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive alternative to ERCP but lacks therapeutic capabilities.
  • Roentgenography may demonstrate nonspecific findings ranging from a distended loop of small intestine (ie, sentinel loop), calcifications, radio-opaque gallstones, dilation of the transverse colon (ie, cutoff sign), ascites, peripancreatic extraluminal gas bubbles, ileus, left-sided basal pleural effusion, and blurring of the left psoas margin to pancreatic calcifications from chronic or recurrent pancreatitis.
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Histologic Findings

  • Acute pancreatitis is characterized by enzymatic necrosis and inflammation of the pancreas. Focal areas of fat necrosis are interspersed with areas of interstitial hemorrhage secondary to destruction of blood vessels. In severe cases, large blue-black hemorrhagic foci are interspersed with yellow-white chalky areas of fat necrosis.
  • Chronic pancreatitis is characterized by irreversible destruction of the pancreatic parenchyma and subsequent replacement with fibrous tissue. Histologic features include intraglandular fibrosis, acinar cell destruction, lymphocytic infiltration, and pancreatic duct obstruction. The pancreatic ducts are dilated and obstructed with protein plugs in their lumens. Grossly, the gland is hard.
  • Pancreatic pseudocysts are localized collections of pancreatic secretions walled off by granulation tissue that lack a true epithelial lining. The stomach, duodenum, small bowel, colon, or omentum may abut or form part of the pseudocyst capsule.
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Contributor Information and Disclosures
Author

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sasha D Adams, MD  Resident Physician, Department of Surgery, University of Texas at Houston School of Medicine

Sasha D Adams, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, and Association of Women Surgeons

Disclosure: Nothing to disclose.

Patrick B Thomas, MD  Fellow, Department of Pediatric Surgery, Texas Children's Hospital

Patrick B Thomas, MD is a member of the following medical societies: American Medical Association and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jorge H Vargas, MD  Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

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This CT scan of the abdomen in the region of the pancreas demonstrates a large well-marginated cystic structure that represents a pancreatic pseudocyst.
This real-time ultrasonography of the abdomen, with attention to the right upper quadrant, revealed a loculated fluid collection in the hilum of the liver. This was compatible with a pancreatic pseudocyst. Differential diagnosis included a large choledochal cyst.
 
 
 
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