History and Physical Examination
Classically, pancreatitis in adults presents with midepigastric pain radiating to the back. In children, the presenting signs and symptoms can be quite varied. Most commonly, a child with acute pancreatitis presents with abdominal pain (94.9%), vomiting (60.4%), and nausea (58.2%). [4] Other, less common clinical signs include fever, tachycardia, hypotension, jaundice, abdominal guarding, rebound tenderness, and decreased bowel sounds. Eating may exacerbate the abdominal pain.
Acutely ill children may lie on their side with the hips and knees flexed. The pain typically increases in intensity for 24-48 hours. The clinical course for acute pancreatitis is variable. Often, children may require hospitalization for analgesia, bowel rest, and rehydration with fluid and electrolyte therapy.
Acute hemorrhagic pancreatitis
Acute hemorrhagic pancreatitis rarely occurs in children. This is a life-threatening condition with a mortality rate approaching 50% because of shock, systemic inflammatory response syndrome with multiple organ dysfunction, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), massive gastrointestinal bleeding, and systemic or peritoneal infection.
Physical examination findings associated with hemorrhagic pancreatitis may include a bluish discoloration of the flanks (ie, Grey Turner sign) or periumbilical region (ie, Cullen sign) because of blood accumulation in the fascial planes of the abdomen. Additional signs include pleural effusions, hematemesis, melena, and coma.
Chronic pancreatitis
Chronic pancreatitis in children is associated with trauma, systemic disease, and pancreaticobiliary malformations, most commonly pancreatic divisum. In the United States, the most common cause of chronic relapsing pancreatitis in children is hereditary pancreatitis. Patients with this disease typically present with chronic abdominal pain that can be difficult to treat. These patients have recurrent episodes of upper abdominal pain associated with varying degrees of pancreatic dysfunction and have increased risk of developing pancreatic insufficiency, adenocarcinoma, and pancreatic pseudocysts.
Pancreatic pseudocysts
Children with pancreatic pseudocysts may present with localized abdominal pain and a palpable tender epigastric mass or abdominal fullness. Additional symptoms include jaundice, chest pain, nausea, vomiting, anorexia, weight loss, fever, ascites, and rarely, GI hemorrhage.
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Pediatric Pancreatitis. This computed tomography (CT) scan of the abdomen in the region of the pancreas demonstrates a large well-marginated cystic structure that represents a pancreatic pseudocyst.
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Pediatric Pancreatitis. This real-time ultrasonogram of the abdomen, with attention to the right upper quadrant, reveals a loculated fluid collection in the hilum of the liver. This is compatible with a pancreatic pseudocyst. The differential diagnosis includes a large choledochal cyst.
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Pediatric Pancreatitis. Flow diagram for suspected acute pancreatitis . Etiologic factors and forms of acute pancreatitis and Ranson criteria are reviewed. ABG = arterial blood gas; Alk phos = alkaline phosphatase; ALT = alanine transaminase; AST = aspartate aminotransferase; BUN = blood urea nitrogen; CBC = complete blood cell count; Cr, creat = creatinine; ERCP = Endoscopic retrograde cholangiopancreatography; Gluc = glucose; lab = laboratory; LDH = lactate dehydrogenase; PO2 = partial pressure of oxygen; SBP = systolic blood pressure; and T bili = total bilirubin.
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Pediatric Pancreatitis. Flow diagram for mild pancreatitis. Favorable prognostic signs and medical management for acute pancreatitis, as well as studies used for acute pancreatitis. NPO = nothing by mouth; RUQ = right upper quadrant.
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Pediatric Pancreatitis. Prognostic indicators for severe pancreatitis and flow diagram for intensive care unit (ICU) management. BUN = blood urea nitrogen; CT = computed tomography; NG = nasogastric; and O2 = oxygen; paO2 = partial pressure of oxygen in arterial blood.
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Pediatric Pancreatitis. Flow diagram for diagnosis and treatment of necrotizing pancreatitis. CT = computed tomography; Tx = treatment.
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Pediatric Pancreatitis. Flow diagram for treatment of and studies used for pancreatic pseudocysts. ERCP = Endoscopic retrograde cholangiopancreatography
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Pediatric Pancreatitis. Flow diagram for management of idiopathic recurrent pancreatitis. Etiologies for acute pancreatitis. CBD = common bile duct; ERCP = Endoscopic retrograde cholangiopancreatography
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Pediatric Pancreatitis. Flow diagram for management of pancreatic abscess. Definition of an abscess.
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Pediatric Pancreatitis. A patient with acute gallstone pancreatitis underwent endoscopic retrograde cholangiopancreatography (ERCP). The cholangiogram showed no stones in the common bile duct and multiple small stones in the gallbladder. In this image, the pancreatogram shows narrowing of the pancreatic duct in the area of the genu, the result of extrinsic compression of the ductal system by inflammatory changes in the pancreas.
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Pediatric Pancreatitis. Abdominal computed tomography (CT) scan from the same patient as in the previous image showing pancreatic enlargement and peripancreatic fat stranding. The gallstones are not visible.
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Pediatric Pancreatitis. Pancreas divisum associated with minor papilla stenosis causing recurrent pancreatitis. Because pancreas divisum is relatively common in the general population, it is best regarded as a variant of normal anatomy and not necessarily as a cause of pancreatitis. In this case, note the bulbous contour of the duct adjacent to the cannula. This appearance has been termed a santorinicele. A dorsal duct outflow obstruction is the probable cause of pancreatitis when a santorinicele is present and associated with a minor papilla that accommodates only a guidewire.
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Pediatric Pancreatitis. Normal-appearing ventral pancreas in a patient with recurrent acute pancreatitis. The dorsal pancreas (not pictured) showed evidence of chronic pancreatitis.
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Pediatric Pancreatitis. Computed tomography (CT) scan of the abdomen in a child with traumatic pancreatitis. The fluid collection adjacent to the pancreas will become a pseudocyst. Note that the pancreas is lacerated, nearly cut in half, by the force of the abdominal trauma. Also, note the typical location of this injury in relation to the vertebral column.
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Pediatric Pancreatitis. Computed tomography (CT) scan of a young man who was referred after 2 weeks into his second bout of severe acute pancreatitis. Gravely ill, he had fever and leukocytosis as well as hypotension requiring pressors and respiratory distress requiring mechanical ventilation. His abdominal CT scan shows severe acute pancreatitis. A percutaneous drain was placed in the dominant fluid collection to establish drainage while he was given imipenem/cilastatin, which stabilized his condition.
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Pediatric Pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) in the same patient as in the previous image excluded suppurative cholangitis and established the presence of annular pancreas divisum. The dorsal pancreatogram showed extravasation into the retroperitoneum, and a sphincterotomy was performed on the minor papilla. As shown in this radiographic film, a pigtailed nasopancreatic tube was then inserted into the dorsal duct and out into the retroperitoneal fluid collection. The other end of the tube was attached to the bulb suction and monitored every shift.
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Pediatric Pancreatitis. While percutaneous drains removed loculated fluid collections elsewhere in the abdomen in the same patient as in the previous image, the nasopancreatic tube contained the retroperitoneal fluid collection. One week later, the retroperitoneal fluid collection was much smaller, as shown in this radiographic film (the image is reversed in the horizontal direction). By this time, the patient was off pressors and was ready to be extubated.
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Pediatric Pancreatitis. In the same patient as in the previous image, 4 months later, after the pseudocyst was converted into a pseudocystogastrostomy using minimally invasive techniques, the pancreatogram revealed the more proximal pancreatic duct.
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Pediatric Pancreatitis. In the same patient as in the previous image, a guidewire was placed into the dorsal duct, crossed the stenotic area, and advanced into the proximal duct. A dilating catheter was then advanced over the wire to enlarge the stenosis. The duct was subsequently stented.
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Pediatric Pancreatitis. Six months after severe acute pancreatitis, the same patient as in the previous image remained symptom free and was living independently. As shown in this follow-up abdominal computed tomography (CT) scan, minimally invasive techniques were successful in removing the pockets of infection, restoring the integrity of the pancreatic ductal system. These techniques also preserved the endocrine function of the pancreas, and at the time of this follow-up, the patient had no evidence of diabetes mellitus.
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Pediatric Pancreatitis. Familial adenomatous polyposis syndrome in a patient with persistent pancreatitis due to a partially obstructing ampullary adenoma. The pancreatogram shown here reveals a very prominent ductal system. Because the patient had undergone several previous abdominal operations, she opted to have an endoscopic ampullectomy.
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Pediatric Pancreatitis. In this radiograph from the same patient as in the previous image, it can be seen that stents were placed into the biliary and pancreatic ductal systems following ampullectomy. The smoldering pancreatitis resolved within a week, the stents were subsequently removed, and the patient participated in an endoscopic surveillance program, with no recurrence at the time of this article's publication.
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Pediatric Pancreatitis. Recurrent pancreatitis associated with pancreas divisum in an elderly man. This pancreatogram of the dorsal duct shows a distal stenosis with upstream chronic pancreatitis. After the stenosis was dilated and stented, the patient's pain resolved, and he improved clinically during 1 year of stent exchanges on a quarterly basis. Follow-up computed tomography (CT) scans showed resolution of an inflammatory mass. Although ductal biopsies and cytology were repeatedly negative, pain and pancreatitis returned when the stents were removed. The patient developed duodenal outflow obstruction and was sent to surgery; a Whipple procedure revealed a periampullary adenocarcinoma (of the minor papilla).
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Pediatric Pancreatitis. Computed tomography (CT) scan of a patient initially seen for recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) showed a submucosal nodule in the antrum, which prompted a referral to another center, with a request for endoscopic ultrasonography and polypectomy. Because the endoscopic ultrasonogram was indeterminate, a polypectomy was attempted. That evening, the patient developed progressively severe epigastric abdominal pain radiating to the back and presented to an emergency department. She had a leukocytosis and a mild elevation of her lipase and was admitted with a diagnosis of pancreatitis. This CT scan of her abdomen shows circumferential hypodense thickening of her antrum, with a normal-appearing pancreas. A small portion of pancreatic tissue was later identified as pancreatic rectitis in the pathology specimen.
