Pancreatic ascites presenting in infancy, with review of the literature

Ascites in Children: A Single-Center Experience of 27 Years

OBJECTIVES

The aim of our study was to describe the changing prevalence, demographic features, etiologies, and treatment of ascites in children hospitalized during a 27-year period at the Johns Hopkins Hospital (Baltimore, MD).

METHODS

We retrospectively reviewed discharges from 1983 to 2010 to select patients whose records included a diagnosis of ascites. We assessed the etiologies and degrees of ascites (ascites grade 1 detectable only by radiologic tests; ascites grades 2 and 3 recognized by moderate and marked abdominal distension by physical examinations).

RESULTS

We classified 518 children into 9 etiology groups: intrahepatic disease (IH) (105), hepatic vein outflow obstruction (HVOO) (45), congestive heart disease (CH) (33), nephrotic syndrome (NS) (36), pancreatitis (26), inflammatory and infectious diseases (77), malignancy (49), idiopathic (71), and miscellaneous (76). IH and CH were predominant in the younger age group (0-5 years) versus HVOO, pancreatitis, and malignancy in the older age group (13-21 years) (P < 0.001). The prevalence of ascites increased over time from 1983 to 2006 and declined thereafter. Ascites grade 1 was more common than ascites grades 2 and 3 in all the groups (P = 0.048). IH and NS were more likely to have ascites grade 2 and 3 (P = 0.02). Although spironolactone was more frequently used in the IH group versus other etiologies, furosemide was used more frequently in NS and CH versus other etiologies (P < 0.001).

CONCLUSIONS

The increased prevalence of ascites during the initial study period could reflect improved detection radiologic detection. The proportion of severe ascites and the various medical treatments differed among the etiologic groups.

Pathophysiology, diagnosis, and management of pediatric ascites

The pediatric population has a number of unique considerations related to the diagnosis and treatment of ascites. This review summarizes the physiologic mechanisms for cirrhotic and noncirrhotic ascites and provides a comprehensive list of reported etiologies stratified by the patient's age. Characteristic findings on physical examination, diagnostic imaging, and abdominal paracentesis are also reviewed, with particular attention to those aspects that are unique to children. Medical and surgical treatments of ascites are discussed. Both prompt diagnosis and appropriate management of ascites are required to avoid associated morbidity and mortality.

Successful Management of Pancreatic Ascites with both Conservative Management and Pancreatic Duct Stenting

Pancreatic ascites is a rare complication and should be suspected in patients with chronic alcoholism and pancreatitis presenting with ascites. The etiology is likely from a pancreatic pseudocyst leakage or due to ductal disruption. Treatment is controversial but includes conservative medical therapy or endoscopic transpapillary pancreatic duct stenting or surgery. We present a case of pancreatic ascites in a patient with alcohol use and chronic pancreatitis. Patient received conservative therapy including octreotide. An endoscopic retrograde cholangiopancreatography was performed, which confirmed a pancreatic duct dehiscence with extravasation of the injected contrast. This was treated with placement of a stent. Patient improved clinically and symptomatically. This case report augments the existing data from two prior reported case series, and this modality of management should be actively pursued in such cases.

Pancreatic ascites: study of therapeutic options by analysis of case reports and case series between the years 1975 and 2000

OBJECTIVE

Because of the low incidence of pancreatic ascites, only case reports and case series have been published, and no randomized controlled trials have been performed to find out which is the best therapeutic approach. The aim of this study was to evaluate the utility of the different treatments for pancreatic ascites by a thorough review of all case reports described in the literature in which an independent analysis of the efficacy of the treatment administered to each patient is possible.

METHODS

We conducted an analysis of all case reports and case series of pancreatic ascites published between 1975 and 2000 in which clinical data of every patient could be identified individually. A total of 139 cases were studied. Clinical characteristics, treatments administered, and response to therapy of every patient were registered. Conservative therapy included drainage of ascitic fluid, total parenteral nutrition and diet, and somatostatin analogues. Interventional therapy was either endoscopic or surgical.

RESULTS

After multivariate analysis, the only treatments related to success were surgery (adjusted OR = 8.2, 95% CI = 3.0-22.9) and transpapillary stent (adjusted OR = 7.3, 95% CI = 0.8-62.9). No significant relationship was found between failure or death and the use of other treatments, age, sex, year of publication, underlying disease, site of leakage, or serum amylase levels. The apparent lack of effect of somatostatin analogues could be attributed to the small number of cases and the heterogeneity of the dosages.

CONCLUSIONS

Conservative therapy is not advisable for pancreatic ascites because of the high proportion of failures. Interventional therapy with surgery or transpapillary stent has a positive effect in the clinical outcome.

Endoscopic treatment of pancreatic ascites

Pancreatic ascites, etiologically related to a leaking pseudocyst or ductal disruption, has been treated medically with hyperalimentation, somatostatin analog, and large-volume paracentesis. Surgery is ultimately required in more than 50% of such patients. Mortality figures in patients with pancreatic ascites approximate 15% to 25% with either treatment modality. We describe 4 patients who were found to have ductal disruptions in conjunction with pancreatic ascites who responded to transpapillary pancreatic duct endoprosthesis placement. There has been no recurrence of ascites in these patients at a mean follow-up of 12 months following stent-retrieval. Further evaluation of endoscopic therapy for pancreatic ascites appears warranted.

Endoscopic therapy of pancreatitis in the pediatric population

Six children with chronic relapsing pancreatitis or acute post-traumatic pancreatic pseudocyst underwent therapeutic pancreatography at the time of ERCP. Procedures included pancreaticobiliary sphincterotomy, pancreatic duct stone removal, and endoprosthesis placement. Four of five patients with chronic pancreatitis had significant symptomatic improvement, whereas the patient with pseudocyst had rapid resolution of symptoms and cyst. Complications were limited to mild pancreatitis in a subset of patients. With the capability of obviating or delaying the need for palliative pancreatic surgery, therapeutic pancreatography deserves additional evaluation in the pediatric patient.

Papillary cystic cancer of the pancreas: diagnostic difficulties

Pancreatic tumors rarely present in childhood. Diagnostic difficulty and inappropriate treatment may result especially when the lesions have a cystic component. Two cases of papillary cystic carcinoma of the pancreas in teenage girls are presented. Optimal treatment of such lesions in the head of pancreas consists of partial pancreaticoduodenectomy preserving the pylorus when possible.