Pancreatitis in Children

A Retrospective Review of Children followed up with the Diagnosis of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, the frequency of which increases in childhood.

AIM

To investigate the demographic, etiological, clinical, laboratory, and radiological characteristics of children followed up with the diagnosis of AP. The study also included genetic studies of recurrent cases.

MATERIALS AND METHODS

This retrospective cohort study included pediatric patients <18 years of age with AP who were followed up with recurrent pancreatitis in the Pediatrics Department of a University Hospital between January 2010 and April 2021. Patients who met at least 2 of the 3 criteria defined by the International Pediatric Pancreatitis Study Group (INSPPIRE) were accepted as AP. Demographic, etiological, and clinical data of the patients, developing complications, pathological evaluation of the samples, and genetic analysis results were obtained from the patient files. The obtained data were statistically analyzed using the SPSS version 26.0 program. Descriptive statistics of the data were expressed as mean ± standard deviation, median, minimum and maximum values, number (n), and percentage (%). Kolmogorov-Smirnov test, Mann Whitney U test, Chi-square test and Fischer test were used.

RESULTS

Fifty-four (50%) female and 54 (50%) male patients with a mean age of 9.96 ± 4.8 years who met the study criteria were included in the study. In the follow-up, it was reported that acute recurrent pancreatitis developed in 23 (21%) patients and chronic pancreatitis developed in 8 (7%) patients. The most common complaints were abdominal pain (94.4%), and vomiting (60.2%), followed by malnutrition (36.1%), nausea (17.6%), diarrhea (13%), and fever (13%). Etiology could not be determined in 19.4% of the patients. It was noted that the genetic predisposition of the patients played a role in the development of recurrent and chronic pancreatitis. Amylase, lipase, and CRP values, which are among the laboratory parameters showing the severity and prognosis of AP, were found to be significant.

CONCLUSIONS

Sociocultural and demographic data of the patients should also be taken into account. Gene sequences that cause to genetic predisposition should be determined in recurrent and chronic pancreatitis cases. Acute pancreatitis should be considered in the differential diagnosis of patients with frequent abdominal pain and vomiting.

The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents

Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

Suspected Case of Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 Infection Presenting as Acute Pancreatitis in a Child With Leukemia

Multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 may present with fever, elevated inflammatory markers, and multiorgan involvement. Although the gastrointestinal system is commonly affected in MIS-C patients, associated necrotizing pancreatitis is rare. We present an 11-year-old boy with B-cell acute lymphoblastic leukemia in remission undergoing maintenance chemotherapy presenting with acute necrotizing pancreatitis. He developed fevers, fluid and electrolyte imbalance, respiratory distress, cytopenias, and coagulopathy, and was found to have markedly elevated inflammatory markers and positive SARS-CoV-2 antibodies. The patient met criteria for MIS-C and was treated with intravenous immunoglobulin with significant clinical improvement. This is the first known reported case of a child with B-cell acute lymphoblastic leukemia who met criteria for MIS-C presenting as acute pancreatitis, and highlights the importance of considering a broader differential for pancreatitis in children given the current SARS-CoV-2 pandemic.

Normal pancreatic thickness values in healthy children: an MRI study

INTRODUCTION

Normal pancreatic thickness values on ultrasound (US) have been defined in literature. However, there is insufficient information about normal pancreatic measurements acquired from computed tomography (CT) or magnetic resonance imaging (MRI). To define normal pancreatic thickness measurements acquired from different localizations in order to provide reference values for more objectively identified parenchymal thickness changes.

MATERIALS AND METHODS

A retrospective evaluation was made of the abdominal MRI examinations of 162 pediatric patients. Patients with any pancreatic disease, or chronic gastrointestinal inflammatory disease were excluded from the study. Measurements were taken from T2-weighted images.

RESULTS

Evaluation was made of 162 children, comprising 82 (50.6%) males and 80 (49.3%) females with a mean age of 9.8 ± 2.4 years. Mean pancreatic thickness was 18.3 ± 3.1 mm, 10.2 ± 2.9 mm, 14.9 ± 3 mm, 14.9 ± 3.3 mm in head, neck, body and tail localizations, accordingly. A positive correlation was determined between age, height, weight, body mass index (BMI) and pancreatic thickness in all the anatomic localizations (r > 0.55, p < 0.05). No significant difference was determined with gender. Interobserver agreement between two researchers was moderate and strong according to the different anatomic localizations.

CONCLUSIONS

The defined normal ranges are mostly consistent with previously published US and CT based values. Pancreatic thickness values were positively correlated with age, height, weight and BMI for all four anatomical regions of the pancreas. Knowledge of normal pancreatic thickness values will increase the diagnostic accuracy of radiologists in the assessment of pancreatic diseases and may aid in interpreting atrophy in the setting of chronic pancreatitis.

Posaconazole-Induced Acute Pancreatitis: A Rare Side Effect in a Child with Chronic Granulomatous Disease

Introduction: Pancreatitis is an inflammatory disease of the pancreas. Drug-induced pancreatitis is an important cause of pancreatitis. There are two pathological types of acute pancreatitis, including pancreatic edema with a mild course and pancreatic necrosis with a poor prognosis. Some agents can induce pancreatitis, but so far, posaconazole-induced pancreatitis in children has been not reported. Here, we describe the case of a child with acute pancreatitis who received posaconazole. Case Presentation: A 10-year-old girl with a three-year history of chronic granulomatous disease (CGD) was admitted to hospital due to epigastric pain, nausea, vomiting, loss of appetite, and fever for the last four days. The pain was persistent and prominent in the periumbilical area. The patient was on lifelong antifungal prophylaxis for her illness. On abdominal sonography, the head of the pancreas was inflated, which can indicate pancreatitis. All the medications were discontinued at the time of admission, and along with sufficient hydration, acetaminophen was administered for the patient’s pain. One, three, and twelve months after discharge, the patient was visited for follow-up with no signs of stomach discomfort, and the lab data was within the normal limits. CGD is a rare disease in which the phagocytes fail to produce hydrogen peroxide. Such patients are prone to bacterial and fungal infections. Conclusions: In conclusion, this is the second case of posaconazole-induced pancreatitis and the first case in children; thus, we recommend that physicians should be aware of the signs of pancreatitis in high-risk individuals like immunocompromised pediatric population.

Pediatric Pancreatitis: Outcomes and Current Understanding

Aim:

The aim of this study was to analyze the clinical spectrum of pediatric pancreatitis and review current literature with regard to concepts of disease and management approaches.

Materials and Methods:

This is a retrospective analysis of pancreatitis patients admitted to a tertiary referral pediatric surgical unit from March 2013 to September 2018.

Results:

There were 106 patients from 1 year to 18 years with median age group between 11 and 15 years and equal gender distribution. Sixty-two children had acute pancreatitis (AP), with 13 of them having recurrent episodes. Forty-four patients had chronic pancreatitis (CP). Definite etiology was found in 11 AP patients. All patients had radiological changes. All AP patients were treated symptomatically except those with correctable underlying etiology. Sixteen with CP required intervention in the form of endoscopic retrograde cholangiopancreatography sphincterotomy/stenting or surgery. There were two mortalities. One with acute necrotizing pancreatitis and one CP girl due to the complication of diabetes mellitus, unrelated to episode of pancreatitis. All others are well at the last follow-up.

Conclusion:

Pediatric pancreatitis is a disease with a wide spectrum, but management can be standardized. Newer studies reveal that certain genetic mutations make children more susceptible to pancreatitis. Increasing incidence must prompt us to evaluate further so as to better equip ourselves to managing this disease entity in all its forms and evolve preventive strategies.

Clinical features of acute pancreatitis in people of different age groups: A retrospective analysis

BACKGROUND

Acute pancreatitis (AP) is one of the common causes of acute abdomen in clinical practice. In the past, patients with AP were mostly young adults. However, in recent years, with the growth and aging of our country's population, the incidence of AP in the elderly and children is also on the rise. The clinical manifestations of AP at different age groups are slightly different due to their physiological characteristics. The clinical manifestations of elderly and children are atypical, which can easily lead to misdiagnosis and missed diagnosis.

AIM

To analyze the clinical features of AP in people of different age groups.

METHODS

In this retrospective clinical trial, 1758 cases of AP were enrolled from January 2003 to June 2016, and they were divided into three groups according to age: <18, 18-60, and ≥ 60 years old. The general clinical data, etiology, severity of AP, complications, clinical course, prognosis, and biochemical criteria for AP were summarized in different age groups.

RESULTS

In the < 18 age group, the incidence of AP in male patients (53.8%) was slightly higher than that of females (46.2%); the proportion of mild AP (MAP) (78.5%) was higher than those the other two groups; and the rates of complications and mortality were significantly lower than those of the other two groups (P < 0.05). In the 18-60 age group, the incidence of AP in male patients (71.0%) was higher than that of the other two groups (P < 0.05); the incidence of alcoholic and hyperlipidemic pancreatitis (13.4%, 21.5%) was higher than that of the other two groups (P < 0.05); the incidence of pancreatic necrosis in this group of patients was the highest (23.4%); and the rates of peripancreatic exudation, pleural effusion, acute respiratory distress syndrome, and acute renal insufficiency (54.3%, 36.9%, 5.6%, and 6.5%, respectively) were significantly higher than those of the < 18 age group (P < 0.05). In the ≥ 60 age group, the incidence of AP in male patients (57.7%) was slightly higher than that in females (42.3%); the rate of nausea (58.2%) was significantly higher than those of the other two groups (P < 0.05); the incidence of biliary pancreatitis (61.2%) was the highest (P < 0.05); and the proportion of patients with moderately severe AP (43.5%) was higher than those of the other two groups (P < 0.05). The patients in the < 18 age group had the longest hospital stay (17.97 ± 12.14 d; P < 0.05). The proportion of patients staying in the intensive care unit and the mortality rate in the ≥ 60 age group were the highest (4.1% and 13.1%, respectively; P < 0.05). There was no difference in hospitalization cost among patients of different age groups (P > 0.05). There was no significant difference in peripheral blood leukocyte count among the three groups (P > 0.05). Mean C-reactive protein level in the < 18 age group was higher than those of the other two groups. Serum amylase was higher in the ≥ 60 age group than in the < 18 age group. Lipase (LPS) in the ≥ 60 age group was higher than those of the other two groups (P < 0.05), and mean LPS did not differ significantly between the18-60 and < 18 age groups (P > 0.05).

CONCLUSION

The incidence of alcoholic and hyperlipidemic pancreatitis is higher in middle-aged people. Elderly patients with AP are most prone to nausea, and the mortality rate is the highest. When young people have unexplained vomiting and bloating, AP should be suspected.

Genetic Background and Clinical Characters of Pediatric Chronic Pancreatitis: Data and Implications from the East

Background. The clinical pattern and genetic background of juvenile idiopathic chronic pancreatitis (ICP) are yet unclear. Methods. A retrospective study of 73 Chinese juvenile ICP patients was performed, and genetic tests were carried out to detect relevant mutations using direct sequencing technique and high-resolution melting technique. Subjects without pancreatitis served as controls. Results. The SPINK1 c.194+2T>C variant was present in 56.16% and 42.00% of juvenile and adult ICP patients, respectively (p = 0.020), but was not present in any of the control subjects. Thirty-four (46.58%) of the 73 juvenile ICP patients were male, and a significantly higher ratio of male patients in the adult group was identified (46.58% versus 64.00%, p = 0.022). Although most of the juvenile patients presented with abdominal pain (70/73, 95.89%), the patterns of pain attack are significantly different in patients with or without SPINK1 c.194+2T>C mutation. Patients carrying the mutation are more likely to present with recurrent acute pancreatitis (70.70%). Conclusions. The main symptom of pediatric ICP was abdominal pain. SPINK1 c.194+2T>C mutation had a higher occurrence in juvenile ICP patients than in adult group and typically presented with recurrent acute pancreatitis. There may be unidentified factors that lead to a greater incidence rate of ICP in adult male population.