2. ACUTE PANCREATITIS?
• Acute pancreatitis (ap), the most common pancreatic disorder in children.
• According to international study group of pediatric pancreatitis – INSPIRE
• Ap in children has been previously defined as having the presence of at least 2 of the following 3
criteria:
1. Abdominal pain compatible with pancreatic origin,
2. Amylase and/or lipase at least 3 times upper limits of normal, and
3. Imaging findings suggestive/compatible with pancreatic inflammation.
3. CLINICAL MANIFESTATION
• ACUTE PANCREATITIS IS CLASSIFIED ON THE BASIS OF SEVERITY.
• MILD ACUTE PANCREATITIS:
• Local or systemic complications, and usually resolves within the 1st wk after presentation.
This is the most common form of pediatric ap.
• The prognosis for complete recovery in the acute uncomplicated case after 4-7 days is
excellent .
• There is no organ failure
4. MODERATE/SEVERE ACUTE PANCREATITIS
• MODERATELY SEVERE ACUTE PANCREATITIS:
Acute pancreatitis with either transient organ failure/dysfunction (lasting <48 hr) or development of local or
systemic complications
• SEVERE ACUTE PANCREATITIS:
Acute pancreatitis with development of organ dysfunction that persists longer than 48 hr. Persistent organ
failure may be single or multiple.
In severe acute pancreatitis the patient is acutely ill with severe nausea, vomiting, and abdominal pain. Shock,
high fever, jaundice, ascites, hypocalcemia, and pleural effusions can occur.
Mortality rate is approximately 20% and is related to MODS, SHOCK, DIC, RENAL FAILIURE,ARDS, DIC
5. DIAGNOSIS
• As per inspire - presence of at least 2 of the following 3 criteria:
1. Abdominal pain compatible with pancreatic origin,
2. Amylase and/or lipase at least 3 times upper limits of normal, and
3. Imaging findings suggestive/compatible with pancreatic inflammation.
• Serum lipase is considered the test of choice for ap, as it is more specific than amylase. Rises by 4-8 hr, peaks at 24-
48 hr, and remains elevated 8-14 days longer than serum amylase.
• Serum lipase greater than 7 times the upper limit of normal obtained within 24 hr of presentation may predict a
severe course
6. ROLE OF IMAGING
• Abdominal x-rays might demonstrate a
• sentinel loop, dilation of the transverse colon (cutoff sign), ileus, pancreatic calcification (if recurrent)
• blurring of the left psoas margin, a pseudocyst, diffuse abdominal haziness (ascites), and peripancreatic
extraluminal gas bubbles.
• CT has a major role in the diagnosis and follow-up of children with pancreatitis.
• Findings can include pancreatic enlargement; a hypoechoic, sonolucent edematous pancreas; pancreatic
masses; fluid collections; and abscesses
• However, normal imaging may be seen in early acute pancreatitis.
7. CTSI SCORE
• The modified CT severity index is an
extension of the original CT severity
index (CTSI) which was developed by
Balthazar and colleagues in 1990 for
distinguishing mild, moderate and severe
forms of acute pancreatitis.
9. OTHER IMAGING ?
• Ultrasonography is more sensitive than CT for the diagnosis of biliary stones.
Magnetic
• Magnetic resonance cholangiopancreatography and endoscopic retrograde
cholangiopancreatography
These are essential in the investigation of recurrent pancreatitis, non-resolving
pancreatitis, and disease associated with gallbladder pathology.
Endoscopic ultrasonography also helps visualize the pancreaticobiliary system
10. LABS ?
• Apart from Amylase and lipase - other lab investigations in acute pancreatitis
include –
• CBC for hemoconcentration, leukocytosis
• Coagulogram - for coagulopathy,
• Liver Function tests – may show elevated -
γ glutamyl transpeptidase, and
hyperbilirubinemia in case of obstructive causes
• Electrolytes – especially – Calcium levels – total or Ionized to look for
hypocalcemia
11. MANAGEMENT
• A/B/C –
• Airway breathing and circulation management is paramount.
Fluid resuscitation may be required.
IV fluids – 1.5 to 2x daily maintenance
The aim of medical management is to relieve pain, restore metabolic hemostasis
and prevent complications.
12. • ADEQUATE ANALGESIA
• NASOGASTRIC SUCTIONING IS INDICATED IN PATIENTS WHO AREVOMITING
• FEEDING –
ENTERALVS PARENTERAL ?
EARLYVS LATE ?
• ACCTO ESPHGAN AND NASPGHAN –
• ‘Initiation of enteral nutrition in mild AP has proven to be of benefit in both adults and children. Early
initiation of a normal diet (<48 hours) is feasible in most cases. Oral food intake in children with mild AP
is likely to be safe’ - GRADE 1B: Strong recommendation; moderate quality evidence
• Children with mild acute pancreatitis should be nourished preferably via mouth in contrast to nasogastric
route - GRADE 1C: Strong recommendation; low-quality evidence
13. • IN ACUTE SEVERE PANCREATITIS –
• Initiation of EN in predicted SAP and SAP seems safe. Early initiation (<72 hours from presentation) may be
beneficial.
• Enteral nutrition (oral, nasogastric, or nasojejunal as tolerated) should be attempted in children with SAP
within 72 hours from presentation to medical care, once deemed hemodynamically stable.
• GRADE 1C: Strong recommendation; low-quality evidence
Combination of enteral nutrition and parenteral nutrition, rather than parenteral nutrition alone, should be
used in children who do not meet caloric goals with enteral nutrition alone and have not received full calories
for a week into hospitalization.
Jejunal tube feedings should be reserved for those unable to tolerate oral or nasogastric tube feedings in mild
AP.
HOWEVER, NO DATA IS AVAILABLE ON TIMING OF INITATION OF ENTERAL NUTRITION
14. • ANTIBIOTICS – NO ROLE AS PRIOPHYLAXIS
• ONLY INDICATED IN CASE OF INFECTED/NECROSIS.
• PPI’S –TO SUPPRESS GASTRIC ACID SECRETION
• ROLE OF SURGERY ?
Surgical therapy of nontraumatic AP is rarely required but may include-
drainage of necrotic material or abscesses.
Endotherapy for common bile duct stones, ductal strictures, and
for drainage of fluid collections is the standard of care when indicated.
