Acute pancreatitis in children: a 15-year review

Acute pancreatitis in children - morbidity and outcomes at 1 year

OBJECTIVE

To establish short-term and medium-term complications 1-year postdiagnosis, of acute pancreatitis (AP) in children aged 0-14 years.

DESIGN

One-year follow-up of a prospective monthly surveillance of new cases of AP in children under 15 years through the British Paediatric Surveillance Unit (BPSU) from April 2013 to April 2014.

SETTING

A monthly surveillance of >3700 consultant paediatricians and paediatric surgeons in the UK and Ireland using the BPSU.

PATIENTS

Children aged 0-14 years with a new diagnosis of AP.

MAIN OUTCOME MEASURES

The outcomes following AP, including the incidence of complications and comorbidity at diagnosis and at 1 year.

RESULTS

Of the 94 new confirmed cases of AP identified in the UK during the study period, 90 cases (96%) were included in the 1-year follow-up. 30 patients (32%) developed further episode(s) of AP. Over one-fifth of patients developed one or more major complication. At initial admission, the most common of these was pancreatic necrosis (n=8, 9%), followed by respiratory failure (n=7, 7%). Reported complications by 1 year were pseudocyst formation (n=9, 10%), diabetes requiring insulin therapy (n=4, 4%) and maldigestion (n=1, 1%). At 1-year postdiagnosis, only 59% of children made a full recovery with no acute or chronic complications or recurrent episodes of AP. Two patients died, indicating a case fatality of ~2.0%.

CONCLUSIONS

AP in childhood is associated with significant short-term and medium-term complications and comorbidities including risk of recurrence in approximately a third of cases.

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.

Pain in the Early Phase of Pediatric Pancreatitis (PINEAPPLE Trial): Pre-Study Protocol of a Multinational Prospective Clinical Trial

BACKGROUND

There are unexpectedly large differences between the incidences of acute pancreatitis (AP) as indicated by different hospitals. Retrospective studies suggest that the reason behind this is the large differences that exist between the local managements of abdominal pain at emergency units. Unfortunately, no evidence-based medicine (EBM) guidelines are available to give proper instruction concerning the necessity of serum pancreatic enzyme measurement during abdominal pain.

SUMMARY

Pain in Early Phase of Pediatric Pancreatitis (PINEAPPLE) is an observational, multinational observational clinical trial to explore the route from the first sign of abdominal pain to the diagnosis of pancreatitis (PINEAPPLE trial). The PINEAPPLE-R subtrial is a retrospective review on the records of children (patients under 18) appearing at emergency units - a review of their clinical symptoms, results of imaging examinations and laboratory parameters. The PINEAPPLE-P subtrial is a prospective trial designed to develop a fast and simple EBM guideline that helps to evaluate (in a reliable and cost-efficient way) the necessity of pancreatic enzyme test and abdominal ultrasonography (or even computed tomography) when a child has abdominal pain. The trial has been registered at the ISRCTN registry and has received the relevant ethical approval.

KEY MESSAGE

The PINEAPPLE trial will help to recognize AP in children in a highly efficient manner.

Incidence and Clinical Associations of Childhood Acute Pancreatitis

OBJECTIVES

To establish the UK incidence and clinical associations of acute pancreatitis (AP) in children aged 0 to 14 years.

METHODS

Monthly surveillance of new cases of AP in children under 15 years of age through the British Pediatric Surveillance Unit conducted from April 2013 to April 2014 (inclusive) followed by 1-year administrative follow-up for all valid cases.

RESULTS

Ninety-four cases (48 boys) fulfilled the diagnostic criteria. The median age at diagnosis was 11.2 years (range 1.3-14.9). White children accounted for 61% of the cases compared with 28% from Asian and 5% from African ethnicities. Pakistani children accounted for 18 of 26 (69%) Asian patients and 19% of the total cohort. The incidence of AP in children in the United Kingdom was 0.78 per 100 000/year (95% confidence interval [CI] 0.62-0.96). The incidence in Pakistani children (4.55; 95% CI 2.60-7.39) was sevenfold greater than white children (0.63; 95% CI 0.47-0.83). Of the 94 cases, 35 (37%) were idiopathic; other associations were: drug therapy, 18 (19%); gallstones, 12 (13%); hereditary, 7 (7%); organic acidemias, 7 (7%); anatomic anomalies, 5 (5%); viral infections, 3 (3%); systemic diseases, 2 (2%); and trauma 1 (1%). The most common drug associations were asparaginase (28%), azathioprine (17%), and sodium valproate (17%).

CONCLUSIONS

Although still relatively uncommon in the United Kingdom, on average there is >1 case of childhood AP diagnosed every week. The associations of AP have changed significantly since the 1970-80s. Overrepresentation of Pakistani children is worthy of further investigation.

Early cholecystectomy in children with gallstone pancreatitis reduces readmissions

BACKGROUND

Multiple guidelines exist in adult practice regarding the timing of cholecystectomy for gallstone pancreatitis. Current evidence to support their application to pediatric practice is minimal. This study sought to determine the effect of timing of cholecystectomy for gallstone pancreatitis in children on the risk of readmission.

METHOD

All patients younger than 19years of age presenting to an acute NHS trust in England with a diagnosis of gallstone pancreatitis between 1 January 1999 and 31st December 2009 were included. Patient level data were extracted from the English Hospital Episode Statistic Database. ICD10, OPCS4.6 and hospital administrative data were used to determine: diagnosis, age, associated comorbidities and subsequent procedures performed.

RESULTS

670 cases of gallstone related pancreatitis were recorded in younger than 19 years old between 1999 and 2009 resulting in 3 deaths during this period. The majority (534/670) underwent a cholecystectomy which was performed less than two weeks from primary admission in 33% (174/534) of cases. Cholecystectomy within two weeks provides an actual risk reduction (ARR) of readmission of 57.5% (95% CI 50.1 to 64.4%, p<0.0001, NNT 2). No significant difference was identified in operative complications or mortality following early cholecystectomy in this group (p>0.05).

CONCLUSIONS

Readmissions can be significantly reduced in this population by performing a cholecystectomy within two weeks with no apparent rise in surgical complications.

Predictors of severity in childhood pancreatitis: correlation with nutritional status and racial demographics

OBJECTIVE

Acute pancreatitis is one of the leading causes of rising pediatric hospitalizations in North America. The aim of this study was to assess the role of nutritional status and racial influences on the severity of acute pancreatitis in children.

METHODS

The institutional review board approved this retrospective chart review of children with the diagnosis of acute pancreatitis between the ages of 0 and 18 years hospitalized at the Johns Hopkins Hospital between 1998 and 2008. Parameters studied included biochemical markers associated with pancreatitis, review of severity of illness reflected through the length of stay, and pediatric intensive care unit admission.

RESULTS

The length of in-patient hospitalization was longer for children with imaging findings of pseudocyst or pancreatic necrosis (23.1 ± 26.4 days vs 4.4 ± 10.6 days; P = 0.0074) and malnourished children versus normal weight and obese children (16.5 days for malnourished vs 10.6 days for normal weight vs 10.7 days for obese; P = 0.04). There was also a significant difference in the need for pediatric intensive care unit admission across ethnic groups (18% African American vs 7% white) (P = 0.04).

CONCLUSIONS

Ethnicity and nutritional status may influence the severity and duration of hospitalization among children with pancreatitis.

Asparaginase-associated pancreatitis in children

l-asparaginase has been an element in the treatment for acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma since the late 1960s and remains an essential component of their combination chemotherapy. Among the major toxicities associated with l-asparaginase therapy are pancreatitis, allergic reactions, thrombotic events, hepatotoxicity and hyperlipidaemia. Acute pancreatitis is one of the most common reasons for stopping treatment with l-asparaginase. Short-term complications of asparaginase-associated pancreatitis include development of pseudocysts and pancreatic necrosis. Long-term complications include chronic pancreatitis and diabetes. The pathophysiology of asparaginase-associated pancreatitis remains to be uncovered. Individual clinical and genetic risk factors have been identified, but they are only weak predictors of pancreatitis. This review explores the definition, possible risk factors, treatment and complications of asparaginase-associated pancreatitis.

What have we learned about acute pancreatitis in children?

Pediatric pancreatitis has received much attention during the past few years. Numerous reports have identified an increasing trend in the diagnosis of acute pancreatitis in children and key differences in disease presentation and management between infants and older children. The present review provides a brief, evidence-based focus on the latest progress in the clinical field. It also poses important questions for emerging multicenter registries to answer about the natural history and management of affected children with pancreatitis.

Changing referral trends of acute pancreatitis in children: A 12-year single-center analysis

BACKGROUND

Acute pancreatitis is a painful inflammatory disorder known to occur in children. Recent reports, primarily on the basis of adult data, have suggested an increasing incidence. However, pediatric studies are limited.

OBJECTIVE

The study was performed to examine the frequency of acute pancreatitis in a pediatric population from 1994 to 2007 and to characterize etiologies by age subsets.

PATIENTS AND METHODS

In this retrospective study, cases of pancreatitis were identified by ICD-9 codes and subjected to inclusion criteria.

RESULTS

Two hundred and seventy-one cases of pancreatitis met inclusion criteria. Mean age of the subjects was 13.1 +/- 5.6 years. The recurrence rate was 15.3%. Biliary disease was the most common etiology (32.6%). Acute pancreatitis cases evaluated at a single tertiary care center increased 53% between 1995 to 2000 and 2001 to 2006 (P < 0.02). However, when cases were normalized by all annual pediatric emergency department visits for all medical reasons, the increase was reduced to 22% and lost statistical significance (P = 0.16). The rise was not associated with a change in etiologies or body mass index (BMI).

CONCLUSIONS

This is the first report demonstrating that an increase in pediatric pancreatitis may in part be due to growing referrals to tertiary care centers. The data on etiologies, particularly with regard to differing ages, may be helpful in managing children who present with acute pancreatitis.

Acute and recurrent pancreatitis in children: etiological factors

OBJECTIVES

To describe the clinical picture and outcome, and to assess the etiological factors of acute and recurrent pancreatitis in children.

METHODS

Thirty-six (65.5%) patients with acute and 19 (34.5%) with recurrent pancreatitis were studied. Mean age was 126 (41.3 SD) months; 27 (49.1%) were females.

SETTING

A pediatric referral hospital.

PERIOD

2000-2005.

DESIGN

Cross-sectional.

VARIABLES

Clinical and laboratory data and etiological factors.

STATISTICS

Chi2-test, Fisher test, OR, confidence interval, Student t-test and Mann-Whitney U-test.

RESULTS

The most frequent symptom in acute and recurrent pancreatitis was abdominal pain, followed by vomiting and ileus. The severity of pancreatitis and complications were similar in both groups. Biliary stones, family history of pancreatitis, drug ingestion and hypercalcemia occurred in both groups. Abdominal trauma and acute hepatitis A occurred in patients with acute pancreatitis; triglyceride>5.65 mmol/L, pancreas divisum and DeltaF508 mutation occurred in patients with recurrent pancreatitis. No difference was observed when frequency factors between study groups were compared.

CONCLUSIONS

The clinical picture and etiological factors were similar in both groups. Since one out of every three children with acute pancreatitis in this series presented recurrences, it was not considered to be a 'benign disease'. Fifteen different etiological factors were identified in two-thirds of the cases.

Childhood pancreatitis

Inflammation of the pancreas has many presentations in children and adolescents. The etiology is often elusive, with a great number of cases being idiopathic. However, there have been a number of recent advances in the areas of cell biology, genetics and imaging technology, which should be highlighted. Herein is provided a review for the reader with particular emphasis on some of these newer advances.

Pancreatitis and pancreatic trauma

Many pancreatic disorders in children benefit from a multidisciplinary approach. This is especially true for acute and chronic pancreatitis which has numerous and diverse etiologies. The current management of pancreatitis is reviewed, focusing on recent advances. Children with pancreatitis must be fully investigated, not least to select out those who benefit from specific surgical interventions. The treatment of pancreas divisum, pseudocysts, and fibrosing pancreatitis deserve particular consideration. Management of pancreatic injuries involving the main pancreatic duct is both variable and controversial. Treatment should be individualized depending on the site of injury, timing of referral, presence of associated injuries, and institutional expertise.

Acute pancreatitis in a young girl with the Netherton syndrome

Acute pancreatitis is uncommon in children younger than 15 years. We present the first report on the association of acute pancreatitis with the Netherton syndrome. The Netherton syndrome is an inherited skin disease characterized by ichthyosiform erythroderma, a pathognomonic hair shaft defect ("bamboo hair"), and atopic features. A 14-year-old girl with symptoms and signs of severe acute pancreatitis was admitted to our department. A diagnostic workup could not reveal any common known cause of pancreatitis, and the cause of pancreatitis would most likely be considered idiopathic. However, based on recent reports regarding various pathophysiological mechanisms for both acute pancreatitis and the Netherton syndrome (eg, shearing the 5q locus for the respective gene-associated defects in SPINK1 and SPINK5), we speculate if a possible association may exist. Investigations on pancreatitis and the Netherton syndrome may disclose factors closely involved in the pathomechanisms of both. This notion may be of clinical importance as it adds to the number of potential life-threatening events to patients with the Netherton syndrome.

Chronic pancreatitis with pancreaticolithiasis and pseudocyst in a 5-year-old boy with homozygous SPINK1 mutation

We report a 5-year-old boy with a 5-month history of symptoms owing to chronic pancreatitis. Abdominal imaging revealed a large pseudocyst in the pancreatic tail and concretions in the main pancreatic duct. Successful endoscopic papillotomy and stent implantation were performed. Genetic testing showed homozygous SPINK1-N34S mutation, which is an established risk factor for chronic pancreatitis.

Paediatric acute abdomen

A large proportion of children assessed in hospital with abdominal pain will leave with no definitive diagnosis. The challenge is to treat the majority of children with self-limiting but benign conditions and to swiftly identify and treat the child with an uncommon but potentially life-threatening cause of pain.

Endoscopic drainage of pancreatic pseudocysts in children

BACKGROUND/PURPOSE

Symptomatic pancreatic pseudocysts have traditionally been managed with surgical, percutaneous, and, more recently, endoscopic drainage. Although the role of the latter is well defined in the adult population, its utility in children needs to be clarified. The authors reviewed their experience with endoscopic drainage of pancreatic pseudocyst (EDPP).

METHODS

A retrospective chart review was conducted, and relevant demographic and clinical data were obtained for all patients with pancreatic pseudocysts managed with endoscopic drainage in the period from 1997 through 2001, inclusive.

RESULTS

Three children had successful endoscopic drainage of pancreatic pseudocysts. They were 9, 13, and 14 years old, and were all boys. The etiology of the pancreatitis was idiopathic related to anomalous pancreatic divisum ducts in the first 2 and azathioprine induced in the latter. The first 2 patients had endoscopic transpapillary drainage, whereas the third had an endoscopic cystduodenostomy. All patients had complete resolution of the pseudocyst clinically and radiologically after follow-up periods of 3, 31, and 21 months, respectively. The first needed a subsequent pancreaticojejunostomy for persistent symptoms related to chronic pancreatitis. A successful endoscopic drainage of a posttraumatic pancreatic pseudocyst has previously been reported from our institution.

CONCLUSIONS

This experience would indicate that endoscopic drainage of pancreatic pseudocyst is an effective and relatively safe option of managing this problem in children.

Surgical complications of selected gastrointestinal emergencies: pitfalls in management of the acute abdomen

Complaints referable to the abdomen are common emergency department presentations. Many of these conditions prove to be benign and self-limited, whereas others are potentially catastrophic. Because serious and benign intra-abdominal conditions share many relatively nonspecific symptoms, it is often difficult to identify patients who have life-threatening problems early in the course of their disease. Apart from relieving the patient's symptoms, the emergency physician's primary role is to detect and stabilize life-threatening conditions in a rapid and cost-effective manner.

Pancreatitis in children

OBJECTIVES

To determine the incidence, etiology and outcome of pancreatitis at a regional children's hospital.

METHODS

Chart review of all patients with pancreatitis seen during a 6 year period at the Children's Hospital of Wisconsin. The diagnosis of pancreatitis required either a serum amylase or lipase >3 times normal or radiographic evidence of pancreatitis.

RESULTS

Two hundred fourteen episodes of pancreatitis in 180 patients were documented. The most common etiologies were systemic disease (14%), trauma (14%), drug induced (12%), biliary tract disease (12%), infectious (8%), and idiopathic (8%), which made up 68% of the total cases. Eleven patients died, all from underlying systemic illnesses. The serum amylase and lipase were elevated in 82% and 83% of patients respectively.

CONCLUSIONS

Pancreatitis is more common in children than previously thought. Upon careful assessment fewer cases were found to be idiopathic than in previous series. The outcome of pancreatitis depends on co-morbid conditions.

Severe acute necrotizing pancreatitis associated with lipoprotein lipase deficiency in childhood

An 11-year-old girl with lipoprotein lipase deficiency experienced recurring episodes of abdominal pain. She initially underwent appendectomy for suspected appendicitis; however, the appendix was normal. Pancreatitis was subsequently identified as the cause of her pain.

Acute pancreatitis in childhood: analysis of literature data

GOALS

To review the published experience with acute pancreatitis in childhood.

STUDY

Computerized search of the English medical literature since 1965 using MEDLINE.

RESULTS

Details of 589 patients were reviewed. Mean age was 9.2 +/- 2.4 years (range: 1 week to 21 years). Male to female ratio was 1.2. Etiologies included (n = 589): idiopathic (23%), trauma (22%), structural anomalies (15%), multisystem disease (14%), drugs and toxins (12%), viral infections (10%), hereditary (2%) and metabolic disorders (2%). Diagnosis was based most often on abnormal abdominal ultrasonography (81%) and on elevated serum amylase levels (63%). Radiograph findings were helpful in 34%. In 16% of the patients the diagnosis was based only on laparotomy. Mean hospital stay was 13.2 +/- 2.4 days and TPN was required in 28% of the patients. In 24% of the subjects a surgical intervention was indicated. Recurrence was reported in 9%, most of them with idiopathic and structural etiologies. Fatal outcome was described in 9.7% of the patients.

CONCLUSIONS

Acute pancreatitis of childhood, although considered sometimes as a minor disorder, carries significant morbidity and mortality. Therefore, pediatricians should be more aware of this illness.

Acute pancreatitis in children

OBJECTIVES

Currently, there is no scoring system for predicting severity in acute pancreatitis in children. Our intent was to evaluate the performance of existing scoring systems in children, to develop a system for children, and to examine the etiology of acute pancreatitis in children.

METHODS

A chart review of children with acute pancreatitis was conducted at six centers, three serving as criterion centers and three as validation centers. Ranson and Glasgow scores were calculated for each admission. Additional clinical data were collected, and parameters correlating with severity were incorporated into a new scoring system. Performance characteristics were calculated for each system.

RESULTS

A total of 301 admissions were reviewed, 202 in the criterion group and 99 in the validation group. Eight parameters were included in a new scoring system for children. The parameters were as follows: age (<7 yr), weight (<23 kg), admission WBC (>18,500), admission LDH (>2,000), 48-h trough Ca2+ (<8.3 mg/dl), 48-h trough albumin (<2.6 g/dl), 48-h fluid sequestration (>75 ml/ kg/48 h), and 48-h rise in BUN (>5 mg/dl). When the cut-off for predicting a severe outcome was set at 3 criteria, the new system had better sensitivity versus Ranson and Glasgow scores (70% vs 30% and 35%, respectively) and a better negative predictive value (91% vs 85% and 85%). The specificity (79% vs 94% and 94%) and positive predictive value (45% vs 57% and 61%) fell slightly.

CONCLUSION

The new scoring system performs better in this group than do existing systems.

The changing incidence of acute pancreatitis in children: a single-institution perspective

All cases of pancreatitis examined between 1993 and 1998 were reviewed to determine the etiologic factors and the number of cases per year. Although the incidence increased, the spectrum of etiologic factors did not differ greatly from those in previous series of pancreatitis in children. Pancreatitis in infants was associated with multisystem illness. Idiopathic pancreatitis was uncommon in children younger than 6 years of age and not observed in children younger than 3 years of age.

Acute pancreatitis in children. An Italian multicentre study

AIM

To evaluate the clinical, morphological and aetiological aspects of acute pancreatitis in children in Italy.

PATIENTS

The hospital records of 50 consecutive patients with acute pancreatitis observed in 5 Italian Pediatric Departments were reviewed.

RESULTS

A total of 25 males and 25 females (median age 10.5 years, range 2-17) were studied. Of these patients, 48 (96%) had abdominal pain. The pancreatitis was associated with biliary disease in 10 patients (20%); it was due to viral infection in 6 patients (12%), pancreatic duct abnormalities in 4 (8%, familial chronic pancreatitis in 3 (6%), trauma in 5 (10%) and other causes in 5 (10%); the pancreatitis was of unknown origin in 17 patients (34%). Previous attacks of the disease had occurred in 14 patients. A diagnosis of mild pancreatitis was made in 41 patients (82%) and of severe disease in 9 (18%). One patient with severe pancreatitis died from multiorgan failure. Patients with severe pancreatitis had significantly higher serum concentrations of C-reactive protein than patients with mild pancreatitis. Hospital stay was similar for patients with the mild form and those with the severe form of the disease.

CONCLUSIONS

In Italian children, acute pancreatitis is of unknown origin in about one-third of the children and is recurrent in 28% of the cases. The disease is severe in 18% of the cases.

Successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a child

The successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a 9-year-old boy is described. This case study suggests that there is a role for endoscopic placement of stents in the treatment of pancreatic pseudocysts in children.

Dyspepsia in infants and children

Pathological processes and diseases of the upper gastrointestinal tract have become increasingly recognized over recent years as childhood entities responsible for a variety of upper gastrointestinal symptoms previously labelled as functional or non-organic. The term 'dyspepsia' is an adult one whose definition requires clarification before use in the paediatric context, but it encompasses age-dependent symptoms such as feed-associated irritability in the infant, peri-umbilical pain in the younger child, and heart-burn, nausea, and indigestion in the older child as in adults. The possible organic conditions giving rise to such symptoms are multiple and multiorgan and include: gastro-oesophageal reflux; peptic ulcer disease; upper gastrointestinal Crohn's disease; antroduodenal motility disorders; pancreatitis; cholecystitis; cholelithiasis; biliary dyskinesia; and abdominal migraine. However, Munchausen syndrome by proxy must not be forgotten. Non-ulcer dyspepsia, it is now clear, has a basis in altered gastroduodenal motility and may be amenable to propulsion agents. In many individuals the dyspeptic symptoms of recurrent abdominal pain may be altered by psychotherapeutic intervention. Indeed there remains a proportion of children who undoubtedly have a behavioural or psychological base to their complaint. Nevertheless, with the recent increase in diagnostic yield from improved technical investigative aids available to paediatrics in the last 5-10 years, it is clear that the responsibility of the paediatrician to the child to find a cause of their symptoms is paramount. The variety of presenting features, possible causes of these symptoms, and appropriate investigation and treatment will be discussed, and management algorithms based on published literature and personal practice will be offered.

Surgical therapy and follow-up of pancreatitis in children

BACKGROUND

Acute and chronic pancreatitis in children differ from that in adults both from the etiology and the therapeutic approach. Within the frame of a blunt abdominal trauma-the most frequent cause in children-acute pancreatitis is often detected by emergency laparotomy and external drainage is recommended. Chronic relapsing pancreatitis, and particularly its hereditary form, is very rare in children and requires a different therapeutic concept. The results of surgical therapy for both forms of pancreatitis in childhood were evaluated in the present study.

METHODS

Sixteen patients with acute and chronic relapsing pancreatitis were operated on in our facility between 1976 and 1988. Their history and postoperative course were analyzed in a retrospective study, including a final examination at the end of the follow-up period.

RESULTS

Eight children with acute pancreatitis were operated on at an average age of 6 years and were followed up for an average of 7.5 years, with good results. The remaining children, aged between 3 and 14 years (average age of 9 years), were operated on for chronic relapsing pancreatitis. Our experience with early operative treatment, on average 2.7 years after onset of symptoms, is presented. Only three patients experienced a mild relapse during the follow-up period of 2-13 years (average of 5.4 years).

CONCLUSIONS

For acute pancreatitis in childhood, operative treatment by inner drainage is necessary and effective only in case of complications, should conservative treatment fail. In children with chronic relapsing pancreatitis, the good exocrine and the normal endocrine function of the pancreas in these patients justified the early operation. Timely treatment is recommended in cases with typical changes of the pancreatic duct so as to shorten the relapsing clinical problems of the children and to maintain the function of the pancreas.

Emergency and critical care issues in pediatric rheumatology

The study of critical care issues in pediatric rheumatology is in its infancy, and the available literature is largely case studies and small retrospective series. A child's limited communication skills and the lack of understanding of disease consequences by both parent and child may cause both overuse and underuse of emergency services. To the extent that small case experiences in children with rheumatic diseases do not adequately reflect possible disease presentations or diagnostic and treatment options, pediatric and adult rheumatologists, intensivists, and emergency physicians should readily turn as needed to larger reported experiences in adults with similar conditions.

The evaluation of acute abdominal pain in children

The infant or child that presents with abdominal pain must be evaluated with a careful history, physical examination, and selective laboratory studies. There are a few diagnoses that the emergency physician should always consider as "life threatening." In the event of any uncertainty in the diagnosis of conditions like appendicitis, pyloric stenosis, or intussusception, the child or infant should be observed carefully over time with appropriate laboratory/radiologic studies ordered to further delineate pathology. Ultrasound evaluation of children with abdominal pain continues to be one of the most valuable tools to help diagnose different conditions.

Pancreatic diseases in children

The main congenital anomalies of the exocrine pancreas are reviewed, and several generalized and isolated hereditary pancreatic diseases are discussed. In contrast with adults, the most frequent causes of acute pancreatitis are viral infection, drug induction, and trauma. The dissimilarities between pediatric and acute and chronic pancreatitis are emphasized.