Pediatric Pancreatitis Treatment & Management

Updated: Aug 15, 2016
  • Author: Andre Hebra, MD; Chief Editor: Carmen Cuffari, MD  more...
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Treatment

Approach Considerations

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.

Nutrition has an important role in the management of patients with mild acute pancreatitis. A database analysis of all children admitted with mild acute pancreatitis from a major institution failed to show any relationship between pain severity among those patients who received either a low fat or regular diet compared to those patients who were restricted from oral feeding. [6] Moreover, most patients tolerated their nutrition by mouth when compared with those children who received nutritional therapy either from a nasogastric or jejunal feeding tube.  

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.

Sphincteroplasty is contraindicated in patients with evidence of intrapancreatic ductal obstruction. Pancreatic pseudocysts with associated major ductal disruption or a transected pancreas require operative therapy with cyst enterostomy. Definitive management with subtotal or total pancreatectomy is associated with considerable morbidity and mortality due to loss of both endocrine and exocrine functions of the pancreas. Generally, surgery is not indicated in children; however, it may be considered in cases of intractable pain and diffuse parenchymal damage without ductal dilation.

The use of total pancreatectomy with islet cell transplantation is undergoing evaluation for the treatment of chronic abdominal pain in children with chronic pancreatitis. Islet cell transplantation allows a patient to be treated for the pain of pancreatitis without the very serious adverse effects of a total pancreatectomy, including "brittle diabetes," which occurs when a person's blood glucose level often swings quickly from high to low and from low to high. [7]

Consultations

Treatment of pediatric patients with chronic pancreatitis requires the collaborative efforts of multispecialty teams that include gastroenterologists, surgeons, pharmacologists, nutritionists, child life specialists, psychologists, and psychiatrists.

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Surgical Intervention

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.

However, operative management of chronic pancreatitis in children is controversial. Indications for operative intervention include unsuccessful conservative medical therapy, intractable pain, impaired nutrition, and narcotic addiction. Surgical options include distal pancreatectomy with Roux-en-Y pancreaticojejunostomy (ie, Duval procedure), lateral pancreaticojejunostomy (ie, Puestow procedure), or ERCP sphincteroplasty. A few pediatric patients with chronic pancreatitis and chronic abdominal pain were successfully treated with total pancreatectomy and islet cell transplantation. [7, 8, 9]

Surgical intervention is also indicated for the management of congenital anatomic defects (eg, pancreatic divisum) and other complications associated with acute pancreatitis (eg, pancreatic ascites, intra-abdominal abscess collections, pancreatic pseudocyst).

Pancreatic pseudocysts

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. [10]

Chronic pancreatic pseudocysts (>3 mo) are best treated by surgical interventions. Ultrasonography-guided or CT-guided percutaneous drainage, [11] endoscopic drainage, and internal drainage via cyst gastrostomy or enterostomy 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. It has been 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 interventional choice. The success rate is as high as 85%. Surgical treatment can be reserved for those cases that fail endoscopic treatment.

Pancreatic ductal disruption or compromise

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 invaluable in identifying and determining the site of ductal disruption and directs surgical decision-making to the most appropriate operative procedure. [12, 13, 14]

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Supportive Care and Preoperative 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. [15]

For alleviation of pain, meperidine is preferred over morphine because of its decreased risk of ampullary spasm.

Preoperative studies with ultrasonography and computed tomography (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. Endoscopic retrograde cholangiopancreatography (ERCP) is essential to assess various ductal abnormalities or pseudocyst communication with the pancreatic duct to determine definitive operative therapy.

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