Pediatric Pancreatitis Workup

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

Approach Considerations

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. [3]

Ultrasonography and computed tomography (CT) scanning are the preferred imaging modalities used to diagnose and follow the course of pancreatitis and pancreatic pseudocysts.

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Diagnostic Tests

Amylase levels

Elevated serum or urine amylase levels aid in the diagnosis of pancreatitis and peak 48 hours after onset, although 10-15% of patients with pancreatitis may have levels within the reference range. Serum amylase levels are typically elevated for as long as 4 days—although amylase levels can be elevated in patients with other abdominal conditions, the levels are typically not as high as those found in patients with pancreatitis.

Lipase levels

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. [4]

Other

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.

As many as 20% of children who present with acute pancreatitis develop severe disease that carries an increased morbidity, longer hospitalization, and need for aggressive medical management. A retrospective study showed that malnourished children were more likely to experience a protracted hospitalization independent of all the conventional biochemical parameters associated with an increased risk of disease severity in adults, including hypertriglyceridemia, ethnicity, or history of hepatobiliary disease. [5] In that study, most children with severe malnutrition had comorbid conditions, including cerebral palsy and encephalopathy, that could have masked the typical early clinical symptoms of acute pancreatitis.

One study provided a prognostic tool that may be used clinically to predict the severity of acute pancreatitis in children. [5] In that study, a predictive model based on a high serum lipase level (>19 the upper limit of normal) and a low albumin and white blood cell count was associated with an increased risk of morbidity. The authors concluded that the application of these 3 parameters in clinical practice may help pediatricians to identify those patients who are most at risk in developing severe pancreatitis and can thus help direct a more aggressive clinical management strategy.

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Diagnostic Imaging Studies

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. Computed tomography (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. Magnetic resonance imaging (MRI) is another modality to diagnose pancreatitis and is used for the same indications as CT scanning.

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 (see the image below).

This real-time ultrasonogram of the abdomen, with 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.

CT scanning

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 (see the following images). 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.

Computed tomography (CT) scan of the abdomen in a 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.
Computed tomography (CT) scan of a young man who w 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.
Computed tomography (CT) scan of a patient initial 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.

ERCP and MRCP

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) (see the images below). Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive alternative to ERCP but lacks therapeutic capabilities.

Familial adenomatous polyposis syndrome in a patie 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.
In this radiograph from the same patient as in the 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.
Recurrent pancreatitis associated with pancreas di 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).

Radiography

Roentgenography may demonstrate nonspecific findings ranging from a distended loop of small intestine (ie, sentinel loop), calcifications, radio-opaque gallstones, dilatation 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 Features

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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