Pancreatitis in Children

Acute pancreatitis in children with inflammatory bowel disease: Risk factors, clinical course, and prognosis

OBJECTIVES

To characterize the clinical course of acute pancreatitis (AP) in pediatric inflammatory bowel disease (IBD) patients compared to children with AP without IBD and to identify risk factors associated with AP among IBD patients.

METHODS

This retrospective, single-center study compared clinical characteristics of children (<19 years) with AP with and without concomitant IBD who were hospitalized 2005-2019. We also conducted a risk factor analysis of AP development in pediatric IBD.

RESULTS

Sixty-eight (54% males) patients with 120 episodes of AP were admitted at a median age of 15.3 years. Thirteen patients (14 episodes) had a co-diagnosis of IBD, representing 4% of our IBD patient population. The AP-IBD patients presented with lower amylase levels compared to the non-IBD patients (160 [interquartile range, IQR: 83-231] vs. 418 [IQR: 176-874] U/L, p > 0.01), all had a mild pancreatitis, and none required invasive intervention. The presumed etiology for AP in all IBD patients was IBD-related: IBD flare-up in five, side effects of medications in two, and undetermined in seven. The only risk factor for AP development among IBD patients was IBD-associated arthritis (23% vs. 3% for IBD-non-AP, p = 0.04), while extracolonic Crohn's disease and induction therapy with nutrition were negative risk factors (15% vs. 51%, p = 0.05, and 8% vs. 44%, p = 0.04, respectively). Other parameters, including disease type and medications, were nonsignificant.

CONCLUSION

The clinical course of AP in pediatric IBD patients is mild. Only IBD-associated arthritis emerged as a risk factor for the development of AP, while, unexpectedly, IBD medication did not.

Analgesia for the treatment of acute pancreatitis: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Gastrointestinal hospitalisations in the USA cause over US$130 billion in expenditures, and acute pancreatitis is a leading cause of these hospitalisations. Adequate pain control is one of the primary treatment goals for acute pancreatitis. Though opioids are commonly used for analgesia in these patients, there have been concerns about short-term and long-term side effects of using opioids. Recently, non-opioid medications have been studied to treat pain in patients with acute pancreatitis. This systematic review and network meta-analysis aims to assess the comparative efficacy of analgesic medication for non-severe, acute pancreatitis.

METHODS AND ANALYSIS

We will search multiple electronic databases for randomised controlled trials that study pain management in patients with non-severe, acute pancreatitis. The intervention will be any analgesic for acute pancreatitis in the hospital setting. The comparison group will be patients who received a placebo or other active interventions for pain management. The primary outcomes of interest include pain scores and the need for supplementary analgesia. The secondary outcomes will be serious adverse events, local complications, progression to severe pancreatitis, transfer to the intensive care unit, length of hospitalisation, time to start enteral feeds, 30-day all-cause mortality and Quality of Life Scale scores. If sufficient homogeneity exists among included studies, the findings will be pooled using a traditional pairwise and network meta-analysis. The risk of bias in randomised control trials will be evaluated using the Cochrane Risk of Bias Tool 2.0. The Grading of Recommendations, Assessment, Development, and Evaluation approach will be used to report the certainty of evidence.

ETHICS AND DISSEMINATION

This systematic review will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal. They will give healthcare providers a better awareness of the optimal analgesic medication for pain treatment in non-severe, acute pancreatitis.

ECFS standards of care on CFTR-related disorders: Identification and care of the disorders

This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.

National Trends in Interventions for Pediatric Gallstone Pancreatitis

Introduction: Laparoscopic cholecystectomy (LC) during index hospitalization for gallstone pancreatitis is standard in adult populations. The objective of this study was to evaluate trends in use of LC and endoscopic retrograde cholangiopancreatography (ERCP) for children with gallstone pancreatitis. Materials and Methods: This retrospective cohort study used the Kids' Inpatient Database, spanning 2000-2019, to identify patients aged 18 years or younger with a principal diagnosis of gallstone pancreatitis. The Mann-Kendall trend test was used to assess trends over time. Results: Gallstone pancreatitis occurred in 5028 patients. The rate of LC during index hospitalization ranged from 55.4% to 63.8% (P = .76). Trends demonstrate that LC occurred on average hospital day 4.6 in 2000 and decreased to 3.4 in 2019 (P < .01). Among those undergoing LC, average length of stay (LOS) decreased from 6.8 days in 2000 to 5.1 days in 2019 (P < .01). The rate of ERCP alone decreased from 24.8% in 2000 to 14.0% in 2019 (P = .23). For those undergoing ERCP, average hospital day of ERCP decreased from 3.3 in 2000 to 2.3 in 2019 (P = .07). The rate of undergoing both an ERCP and LC decreased from 19.0% in 2000 to 8.5% in 2019 (P = .13). For patients who underwent either LC or ERCP, average LOS decreased from 7.0 days in 2000 to 5.1 days in 2019 (P < .01). For patients who did not undergo a procedure, average LOS decreased from 5.7 days in 2000 to 4.0 days in 2019 (P = .13). Conclusion: The proportion of LC performed during index hospitalizations for children with gallstone pancreatitis has been stable for two decades. However, trends indicate that interventions are occurring earlier, and LOS is becoming shorter.

Trends and clinical characteristics of pediatric acute pancreatitis patients in Japan: A comparison with adult cases based on a national administrative inpatient database

BACKGROUND

/Objectives: Pediatric acute pancreatitis (AP) is not as rare as previously thought, and an increased incidence thereof has been reported. We aimed to clarify the trends and clinical characteristics of pediatric AP in Japan.

METHODS

We utilized the Japanese Diagnosis Procedure Combination inpatient database for patients admitted between April 2012 and March 2021, and extracted the data of patients whose principal diagnosis was AP (ICD-10 code K85) or in whom AP accounted for most of the medical expenses. Patients were classified into pediatric (≤18 years) and adult (age >18 years) groups.

RESULTS

We included 3941 AP cases in pediatrics and 212,776 in adults. AP cases accounted for 0.08 % of all admissions in pediatrics and 0.33 % in adults, with upward trends during the study period. The proportion of AP patients among all admissions was increased with advancing age in pediatrics. Compared to adults, pediatric AP patients had a smaller proportion of severe cases (22.9 % vs. 28.7 %; P < 0.001), fewer interventions for late complications (0.2 % vs. 1.3 %; P < 0.001), shorter hospital stays (mean 16.6 days vs. 18.0 days; P = 0.001), lower overall mortality (0.7 % vs. 2.9 %; P < 0.001), and lower mortality in severe cases (1.3 % vs. 5.6 %; P < 0.001). Pediatric cases were more frequently transferred from other institutions and treated at academic hospitals than adults (both P < 0.001).

CONCLUSIONS

There was an upward trend in the proportion of AP among all admissions in pediatrics, with a lower risk of complications and mortality than adult cases.

Pediatric Drug-Associated Pancreatitis Reveals Concomitant Risk Factors and Poor Reliability of Causality Scoring: Report From INSPPIRE

OBJECTIVES

Drug-associated acute pancreatitis (DAP) studies typically focus on single acute pancreatitis (AP) cases. We aimed to analyze the (1) characteristics, (2) co-risk factors, and (3) reliability of the Naranjo scoring system for DAP using INSPPIRE-2 (the INternational Study group of Pediatric Pancreatitis: In search for a cuRE-2) cohort study of acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) in children.

METHODS

Data were obtained from ARP group with ≥1 episode of DAP and CP group with medication exposure ± DAP. Physicians could report multiple risk factors. Pancreatitis associated with Medication (Med) (ARP+CP) was compared to Non-Medication cases, and ARP-Med vs CP-Med groups. Naranjo score was calculated for each DAP episode.

RESULTS

Of 726 children, 392 had ARP and 334 had CP; 51 children (39 ARP and 12 CP) had ≥1 AP associated with a medication; 61% had ≥1 AP without concurrent medication exposure. The Med group had other risk factors present (where tested): 10 of 35 (28.6%) genetic, 1 of 48 (2.1%) autoimmune pancreatitis, 13 of 51 (25.5%) immune-mediated conditions, 11 of 50 (22.0%) obstructive/anatomic, and 28 of 51 (54.9%) systemic risk factors. In Med group, 24 of 51 (47%) had involvement of >1 medication, simultaneously or over different AP episodes. There were 20 ARP and 4 CP cases in "probable" category and 19 ARP and 7 CP in "possible" category by Naranjo scores.

CONCLUSIONS

Medications were involved in 51 of 726 (7%) of ARP or CP patients in INSPPIRE-2 cohort; other pancreatitis risk factors were present in most, suggesting a potential additive role of different risks. The Naranjo scoring system failed to identify any cases as "definitive," raising questions about its reliability for DAP.

Acute pancreatitis in children: risk factors, management, and outcomes

PURPOSE OF REVIEW

Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis.

RECENT FINDINGS

Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis.

SUMMARY

The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.

The epidemiology and clinical features of pediatric acute pancreatitis in north of Guizhou, China

Background

The epidemiological data on distribution of pediatric acute pancreatitis was deficiency. And the purpose of this research was to investigate the epidemiology and clinical features of pediatric acute pancreatitis in the population in north of Guizhou, China.

Design and methods

A retrospective case analysis was conducted to accomplish the aim. Patients who were under 18 years old with acute pancreatitis were recruited. Data were collected directly from Hospital Information System (HIS) after patients were discharged from the hospital.

Results

A total of 95 children aged from 3 to 17 years were collected, 49 patients were boys and 46 were girls. In addition, the percentage of acute pancreatitis occurring in girls aged 15-17 years was significantly higher than that of boys (54.3% vs 36.7%). Meanwhile, the percentage of severe patients over 12 years exceeded 90.0%. Moreover, the proportion of severe acute pancreatitis in girls was significantly higher than that in boys (26.1% vs 10.2%), and 64.7% of severe patients were from 12 to 14. What's more, more patients occurred in May, June, and December and on weekends, 47.1% (8/17) severe cases occurred in May, June, and July, and 47.1% (8/17) severe patients occurred on weekend. The length of hospitalization and hospitalization costs of severe patients were found higher compared to mild patients.

Conclusions

Higher risk of pediatric acute pancreatitis, especially severe acute pancreatitis, in north of Guizhou, China occurred on weekend, during May and June, and among children aged 12-17 years, especially girls. Additionally, severe acute pancreatitis was associated with higher hospitalization costs and longer hospitalization length.

A possible manifestation of pancreas divisum-pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report

BACKGROUND

Pancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.

CASE PRESENTATION

The patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.

CONCLUSION

In children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.

Total pancreatectomy with islet autotransplantation reduces opioid use and improves nutritional support in children with debilitating pancreatitis

BACKGROUND

Chronic pancreatitis (CP) can result in opioid dependence and nutritional challenges in children. Total pancreatectomy with islet autotransplantation (TPIAT) is a viable surgical option in appropriately selected patients. We examined differences between children who met criteria for TPIAT versus those who did not and continued with non-operative management.

METHODS

Retrospective observational cohort study of patients evaluated for TPIAT between August 2014 and July 2020 was performed. Cohort-based analyses between TPIAT and non-TPIAT groups were performed.

RESULTS

Analyses included 121 patients, 69 of whom underwent TPIAT. Demographics, genetic risk factors, and anatomic variants did not differ between groups. TPIAT patients were more likely to have CP (88% vs 71%; p = 0.02), had higher median number of endoscopic retrograde cholangiopancreatography procedures (2.0 vs 1.0; p = 0.0001), and had higher likelihood of opioid use (61% vs 42%; p = 0.04) and nutritional supplementation (23% vs 4%; p = 0.004), compared to non-TPIAT. At 6 months post-TPIAT, patients had lower use of any analgesic pain medications (39% vs 73%; p = 0.0002) and lower use of opioids (9% vs 39%; p = 0.0006), compared to non-TPIAT patients at 6 months after evaluation. At 6 months post-TPIAT, rate of exclusively oral nutrition increased from 77% to 86%, and total parenteral nutrition use decreased from 13% to 0% (p = 0.02).

CONCLUSIONS

In children referred for TPIAT evaluation, there is greater burden of disease in those selected for operation, compared to patients who do not undergo operation. TPIAT achieves lower analgesic pain medication use compared to continuation with non-TPIAT management and achieves freedom from nutritional supplementation. Level of evidence: Retrospective comparative study, Level III.

Pancreatitis-Associated Medication Use in Hospitalized Pediatric and Young Adult Patients With Acute Pancreatitis

OBJECTIVE

The objective of this study is (1) to describe the prevalence of pancreatitis-associated medication (PAM) use at admission and discharge in pediatric and young adult patients hospitalized with acute pancreatitis (AP) and (2) to describe the prevalence of PAM use at admission in patients classified as having idiopathic AP.

STUDY DESIGN

A single-center retrospective study of patients <21 years who were hospitalized with AP or acute recurrent pancreatitis from March 2015 to July 2017 was performed. Charts were reviewed for demographic data, etiology of pancreatitis, comorbidities, and use of PAMs at admission and discharge. PAMs were defined and scored based on an evidence-based classification system, with class I PAMs having strongest evidence for causation. Standard descriptive statistics were used to report prevalence data.

RESULTS

Our cohort was comprised of 119 patients; 50% of patients were using a PAM at admission and 67% were taking a PAM at discharge, reflecting a significant change (P = 0.0009); 44% of patients classified as having idiopathic pancreatitis were taking a PAM on admission, reflecting a possibly missed role of medication in their presentation. Comorbidities significantly associated with PAM use included seizure disorder (P = 0.005) and oncologic disease (P = 0.005). The most commonly used class I PAMs were omeprazole, trimethoprim-sulfamethazole, valproic acid, and 6-mercaptopurine. The increase in prevalence of PAM use at discharge compared to admission was partially driven by addition of omeprazole to the outpatient medication regimen during the hospital stay (P = 0.07).

CONCLUSION

Medications likely play an under-recognized role in pediatric AP. The practice of using proton pump inhibitors in management of AP warrants further study.

Endotherapy in pediatric pancreatitis

PURPOSE OF REVIEW

Some children with acute recurrent and chronic pancreatitis stand to benefit from therapeutic endoscopic interventions. The purpose of this review is to summarize specific endoscopic therapies used for these conditions and highlight areas of future research.

RECENT FINDINGS

Multicenter collaboration and consortium efforts have provided more data now than ever on the technical outcomes and safety of therapeutic endoscopic procedures for pancreatitis in children. Indications are growing but more research is needed to help guide patient selection.

SUMMARY

Advanced endoscopic procedures including endoscopic retrograde cholangiopancreatography, endoscopic-ultrasound guided therapies, and single-operator pancreatoscopy may be used in patients with acute recurrent or chronic pancreatitis to manage pancreatic duct obstruction or local complications including pseudocysts and walled-off necrosis. Patient and procedural factors differ between adults and children. Access to these procedures for younger children is growing, and technical outcomes and adverse event rates appear similar between adults and children.

Long-Term Follow-Up and Outcome of Pediatric Acute Pancreatitis: A Multicenter Study

OBJECTIVE

Over the past decades, the incidence of acute pancreatitis is increasing, but the progression of acute recurrent pancreatitis and chronic pancreatitis is still not well documented in children. The aim of this multicenter study is to delineate the changes that occur in a certain time period in the course of childhood pancreatitis.

MATERIALS AND METHODS

The data of consecutive patients hospitalized with acute pancreatitis between 2010 and 2017 in 4 different pediatric gastroenterology units were reviewed. The clini- cal characteristics of the disease were defined.

RESULTS

A total of 165 patients (55.2% female) were included. Over the years, the rate of acute pancreatitis admissions increased while the duration of hospitalization decreased (P < .05). Nearly two-thirds of the patients with acute pancreatitis resolved spontaneously, 30.9% and 4.3% of the cases developed acute recurrent pancreatitis and chronic pancreatitis, respectively. Furthermore, 27.4% patients with acute recurrent pancreatitis progressed to chronic pancre- atitis, and eventually, 12.7% of cases developed chronic pancreatitis within 3-4 years. Local complications developed in 13.3% of the patients with pancreatitis in this cohort.

CONCLUSION

The result of this study confirmed the increased incidence of acute pancreatitis in recent years. Conversely, the length of hospital stay decreased over the years. Patients with pancreaticobiliary abnormalities or genetic risk factors had a higher rate of progression to acute recurrent pancreatitis or chronic pancreatitis. Therefore, genetic testing and radiological imaging should be considered early in the follow-up of patients with acute pancreatitis having risk factors for progression to acute recurrent pancreatitis/chronic pancreatitis.

Long-term effects of asparaginase-associated pancreatitis

Pancreatitis is a common and severe toxicity that occurs during asparaginase treatment for acute lymphoblastic leukemia, and has received increasing attention during the last decades. However, no consensus regarding follow-up exists. In this commentary, we highlight potential long-term health-related effects following asparaginase-associated pancreatitis, thereby providing clinicians with a framework when following these patients during and after cessation of therapy.

Pancreatic Involvement in the Course of Inflammatory Bowel Disease in Children-A Multi-Center Study

The coexistence of inflammatory bowel disease (IBD) with pancreatic pathology is rare in children. A retrospective analysis of data from 1538 children diagnosed with IBD in 2014-2021 was conducted to determine the frequency and causes of pancreatitis and asymptomatic hyperlipasemia (HL) or hyperamylasemia (HA) in this group of patients. Among the 176 children (11.4%) with pancreatic involvement (PI), acute pancreatitis (AP) was diagnosed in 77 children (43.8%), and HA or HL was observed in 88 children (50.0%). Only a few patients were diagnosed with autoimmune or chronic pancreatitis (6.2%). PI was observed at the time of the IBD diagnosis in 26.1% of the cases. A total of 54.5% of the patients had moderate to severe IBD, and 96% had colonic involvement at the time of diagnosis of PI. Idiopathic PI was the most common (57%), followed by drug-induced PI (37%) and azathioprine (AZA). In patients with AZA-induced AP, the successful introduction of 6-mercaptopurine (6-MP) to therapy was noted in 62.5% of the children. Our results suggest that routine monitoring of pancreatic enzymes in patients with IBD should be performed, especially after the initiation of the AZA treatment. The presence of transient HA/HL in IBD does not necessarily indicate pancreatic pathology.

Endoscopy and Pediatric Pancreatitis

Children and adolescents are increasingly impacted by pancreatic disease. Interventional endoscopic procedures, including endoscopic retrograde cholangiopancreatography) and endoscopic ultrasonography, are integral to the diagnosis and management of many pancreatic diseases in the adult population. In the past decade, pediatric interventional endoscopic procedures have become more widely available, with invasive surgical procedures now being replaced by safer and less disruptive endoscopic interventions.

A population-based cohort study on risk factors for acute pancreatitis: A comparison by age group

BACKGROUND

/objectives: Acute pancreatitis (AP) is an acute inflammatory disorder that can occur in all age groups. The risk of AP has been shown to increase with age. However, no study has compared risk factors for AP according to age group yet. Thus, the aim of this study was to perform such comparison.

METHODS

Clinical data from individuals 20 years of age and older who received a health examination arranged by the Korean national health insurance program in 2009 (n = 4,238,822) were used. First-attack AP was identified using claims data from baseline to December 2018. Incidence and risk factors of AP were analyzed for young (20-39 years old), middle-aged (40-64 years old), and old (over 65 years old) groups.

RESULTS

Incidences of AP in young, middle-aged, and old groups were 16.30, 27.85, and 57.19 per 100,000 person-years, respectively. Smoking, alcohol drinking, diabetes, gallstone, and chronic pancreatitis were associated with increased risk of AP in all age groups. Meanwhile, male, older age, and higher waist circumference were associated with increased risk of AP in middle-aged and old groups. In young and middle-aged groups, risk of AP was increased in the presence of hypertension and dyslipidemia. However, high income was associated with decreased risk of AP in these groups.

CONCLUSIONS

In this population-based cohort study, incidences and risk factors for AP differed according to age group. Thus, a tailored strategy might be needed to prevent AP according to age group.

Pediatric-to-Adult Transfer of Care in Patients With Pancreas Disease: Recommendations for Care and Research Opportunities

Young adults who have experienced recurrent acute pancreatitis and chronic pancreatitis as children or adolescents are vulnerable to poor follow-up and disease management during the transfer from the pediatric to adult healthcare system. Although formalized transition programs for young adults have been developed and described for other disease conditions, no such program has been described for young adults with pancreatic disease. This document is the first expert opinion outlining the important aspects of a transitional care and transfer program tailored to youth with recurrent acute and chronic pancreatitis. We emphasize the unique needs of these patients as they transfer to adult health care and the need for further research. The goal of improved transitional care and transfer is to enhance the services provided to adolescents/young adults with pancreatic disease in both healthcare settings and improve continuity of follow-up care.

Safety and efficacy of minor papillotomy in children and adolescents with pancreas divisum

INTRODUCTION

Pancreas Divisum (PD) is a common pancreatic ductal variant which is twice as common in pediatric patients with acute recurrent pancreatitis (ARP) relative to the general population (14% vs. 7%). Endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy has been performed to facilitate drainage of pancreatic juice from the diminutive minor papilla to prevent pancreatitis and pancreatic damage.

METHODS

We searched our prospectively-maintained endoscopy databases for patients 18 and younger who underwent ERCP with minor papillotomy between 2009 and 2019. Demographic data, indications, procedural interventions and findings, as well as available clinical outcomes data were analyzed.

RESULTS

54 ARP/PD patients underwent ERCP with minor papillotomy. Median age was 14 (range 7-18) years, and 26 (48.1%) patients were female. Post-ERCP pancreatitis developed in 10/54 patients (18.5%). 12-month post-ERCP clinical trajectory was available in 47/54 (87%) patients and most patients (38/47, 80.8%) improved clinically after minor papillotomy, with 9/47 (19.1%) experiencing resolution of pancreatitis episodes and none indicated worsening severity or frequency of pancreatitis episodes following ERCP.

CONCLUSION

The majority of children and adolescents with PD and ARP who underwent ERCP with minor papillotomy experienced subjective improvement in their symptoms following the intervention. These data suggest that ERCP with minor papillotomy for pediatric patients with PD and ARP is beneficial and may be curative in a subset of patients-higher rates of improvement than have been previously reported in adults.

Tendency and risk factors of acute pancreatitis in children with severe motor and intellectual disabilities: A single-center study

OBJECTIVE

Acute pancreatitis (AP) is a life-threatening disease in children with severe motor and intellectual disabilities (SMID). This study aimed to determine the clinical characteristics and causes of AP in children with SMID.

METHODS

We enrolled 29 children with AP admitted to our hospital. Patients were divided into children with SMID (AP with SMID group) and the remaining patients (AP without SMID group). All patients in the AP without SMID group had no pre-existing neurological disabilities. We obtained data on the clinical background of patients, severity of AP, treatments, and outcomes. We enrolled 34 children with SMID without a history of AP (SMID control group) to compare their clinical characteristics with the AP with SMID group. We statistically compared the data between the AP with SMID and AP without SMID groups and between the AP with SMID and SMID control groups.

RESULT

Compared to the AP without SMID group, the AP with SMID group showed significantly more severe pancreatitis (50% vs 12%) and recurrent pancreatitis (58% vs 18%). Moreover, compared with the SMID control group, the AP with SMID group showed significantly more frequent absence of voluntary movement (83% vs 26%), requirement of respiratory devices (75% vs 35%), panhypopituitarism (33% vs 6%), thermoregulatory dysfunction (58% vs 18%), and low serum albumin levels (3.6 vs 4.1 g/dL).

CONCLUSION

AP in children with SMID tended to be associated with severe and recurrent pancreatitis. Children with SMID who had a history of AP had more severe neurological impairment among children with SMID. Hypothalamic-pituitary system dysfunction caused by severe cerebral damage may contribute to the development of AP.

Acute Recurrent Pancreatitis in a Child With INS-Related Monogenic Diabetes and a Heterozygous Pathogenic CFTR Mutation

Given the close anatomical and physiological links between the exocrine and endocrine pancreas, diseases of 1 compartment often affect the other through mechanisms that remain poorly understood. Pancreatitis has been associated with both type 1 and type 2 diabetes, but its association with monogenic diabetes is unknown. Patients heterozygous for pathogenic CFTR variants are cystic fibrosis carriers and have been reported to have an increased risk of acute pancreatitis. We describe a 12-year-old patient with monogenic neonatal diabetes due to a pathogenic heterozygous paternally inherited mutation of the insulin gene (INS), c.94 G > A (p.Gly32Ser), who experienced 3 recurrent episodes of acute pancreatitis over 7 months in conjunction with poor glycemic control, despite extensive efforts to improve glycemic control in the past 4 years. Intriguingly, the maternal side of the family has an extensive history of adult-onset pancreatitis consistent with autosomal dominant inheritance and the proband is heterozygous for a maternally inherited, CFTR variant c.3909C > G (p.Asn1303Lys). Paternally inherited monogenic neonatal diabetes may have promoted earlier age-of-onset of pancreatitis in this pediatric patient compared to maternal relatives with adult-onset acute pancreatitis. Further study is needed to clarify how separate pathophysiologies associated with INS and CFTR mutations influence interactions between the endocrine and exocrine pancreas.

Acute Pancreatitis and Acute Recurrent Pancreatitis in Children: Imaging Findings and Outcomes

OBJECTIVE

The prevalence of acute pancreatitis and acute recurrent pancreatitis in children has increased over the years, and there are limited data about imaging findings. This study aimed to reveal the imaging findings of acute pancreatitis and acute recurrent pancreatitis in children at a tertiary care hospital.

MATERIALS AND METHODS

The patients with acute pancreatitis and acute recurrent pancreatitis diagnosed between January 2007 and December 2018 were included. Demographic and clinical features, follow-up period, and interventions were noted. Imaging features were evaluated for pancreatic enlargement, peripancreatic fluid, and biliary ducts for initial examination and pancreas parenchymal necrosis, peripancreatic collection, walled-off necrosis, pseudocyst, parenchymal atrophy, and biliary ductal dilatation for follow-up.

RESULTS

The study included 74 patients with a mean age of 9 ± 4.9 years. The most common causes of acute pancreatitis and acute recurrent pancreatitis were biliary tract anomalies (n = 21), biliary ductal stones (n = 9), and cystic fibrosis (n = 8). Findings consistent with acute pancreatitis were determined by ultrasound in 40.5% (n = 30/74), whereas by magnetic resonance imaging in 60% (n = 39/65). Forty-one percent of the patients (n = 16) with positive magnetic resonance imaging findings did not show any findings on ultrasound. Acute recurrent pancreatitis was seen in 32 patients (43.2%). Follow-up imaging was performed in 55 patients (74.3%) between 2 months and 11 years. At follow-up, 8 patients had peripancreatic collections (6 walled-off necrosis and 2 pseudocysts).

CONCLUSION

Recognizing the imaging findings of acute pancreatitis and its complications is crucial. Magnetic resonance imaging should be preferred as a second option following ultrasound, with the advantages of biliary ductal system delineation and better characterization of complications.

Postpartum Idiopathic Pancreatitis Complicated by Acute Necrotizing Pancreatitis

Acute pancreatitis (AP) is a common medical condition with a wide variety of etiologies. One of the common but frequently undetected causes of acute pancreatitis is microlithiasis, which can appear as biliary "sludge" in the gallbladder on imaging. While a broad workup should be initiated, endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the diagnosis of microlithiasis. In this case, we present a severe presentation of acute pancreatitis in a teenager within the postpartum period. A 19-year-old woman presented with severe 10 out of 10 right upper quadrant (RUQ) pain with episodes of nausea that radiated to her back. She had no history of chronic alcoholism, illicit drug use, or over-the-counter supplement use, and no familial history of autoimmune disease, or pancreatitis. The patient was diagnosed with necrotizing acute pancreatitis with gallbladder "sludge" using contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP). She followed up with gastroenterology and had a great clinical recovery. Therefore, it is important to consider acute pancreatitis in patients with idiopathic pancreatitis in their postpartum period as they are prone to forming gallbladder "sludge" which can precipitate and cause a variation in gallbladder pancreatitis which can be difficult to detect on imaging.

Pediatric Medical Traumatic Stress in Inflammatory Bowel Disease, Pancreatitis, and Cystic Fibrosis

OBJECTIVES

Known as pediatric medical traumatic stress (PMTS), posttraumatic stress symptoms from medical experiences have not been explored in children with chronic gastrointestinal diseases. This cross-sectional study of children and adolescents with inflammatory bowel disease, chronic pancreatitis and cystic fibrosis, aimed to (1) estimate the prevalence of medical potentially traumatic events (PTEs) and PMTS, (2) explore potential risk factors for PMTS, and (3) explore potential consequences of PMTS.

METHODS

This cross-sectional study used validated, self-report measures to evaluate PTEs and PMTS. Descriptive statistics and regression analyses were used to achieve study objectives.

RESULTS

Over two-thirds of children reported a medical potentially traumatic event (91 of 132, 69%). Forty-eight had PMTS symptoms (36%). PMTS was associated with medication burden, emergency and intensive care visits, and parent posttraumatic stress disorder in multivariate analysis. Potential consequences associated with PMTS included school absenteeism, home opioid use, poor quality of life, and parent missed work.

CONCLUSIONS

A substantial portion of our cohort reported medical PTEs and PMTS. The exploratory analysis identified potential associations between PMTS and illness factors, parent posttraumatic stress disorder, and functional impairments. Further studies of PMTS detection, prevention and treatment are integral to optimizing these children's health and quality of life.

Admission risk factors and predictors of moderate or severe pediatric acute pancreatitis: A systematic review and meta-analysis

Introduction

Pediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP.

Methods

We conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity.

Results

We included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe.

Discussion

Many predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.

Pancreatic family history does not predict disease progression but connotes alcohol consumption in adolescents and young adults with acute pancreatitis: Analysis of an international cohort of 2,335 patients

Background

In pediatric acute pancreatitis (AP), a family history of pancreatic diseases is prognostic for earlier onset of recurrent AP (ARP) and chronic pancreatitis (CP). No evidence supports the same association in adult-onset pancreatitis. Age-specific reasons for familial aggregation are also unclear. We aimed to examine the prognostic role of pancreatic family history for ARP/CP and observe possible underlying mechanisms.

Methods

We conducted a secondary analysis of the Hungarian Pancreatic Study Group’s (HPSG) multicenter, international, prospective registry of patients with AP, both children and adults. We compared the positive family history and the negative family history of pancreatic diseases, in different age groups, and analyzed trends of accompanying factors. Chi-square and Fisher exact tests were used.

Results

We found a higher rate of ARP/CP in the positive pancreatic family history group (33.7 vs. 25.9%, p = 0.018), peaking at 6–17 years. Idiopathic AP peaked in childhood in the positive family history group (75% 0–5 years) and was consistently 20–35% in the negative group. A higher rate of alcohol consumption/smoking was found in the positive groups at 12–17 years (62.5 vs. 15.8%, p = 0.013) and 18–29 years (90.9 vs. 58.1%, p = 0.049). The prevalence of diabetes and hyperlipidemia steadily rose with age in both groups.

Conclusion

Positive family history most likely signifies genetic background in early childhood. During adolescence and early adulthood, alcohol consumption and smoking emerge—clinicians should be aware and turn to intervention in such cases. Contrary to current viewpoints, positive pancreatic family history is not a prognostic factor for ARP and CP in adults, so it should not be regarded that way.

Epstein-Barr virus-associated acute pancreatitis: a clinical report and review of literature

Background

Acute pancreatitis is a disorder of reversible inflammation of the pancreas. Only a few cases are related to infections and the most common pathogens are the viruses responsible for mumps, parotitis, and influenza. Epstein-Barr virus (EBV)-associated acute pancreatitis is a rare condition and it may occur in children and adults.

Case presentation

A 3-year-old female was admitted to the “G. Di Cristina” Children's Hospital in Palermo for vomiting and abdominal pain. Laboratory investigations revealed elevated amylase and lipase, with normal liver function tests. Abdominal ultrasound demonstrated an enlarged pancreas, with hypoechogenic areas; no biliary lithiasis was observed. Infectious disease serology was positive for the presence of EBV VCA IgM and IgG. A diagnosis of EBV-associated acute pancreatitis was made. The patient was treated conservatively and recovered.

Conclusions

Acute pancreatitis is rarely associated with EBV infection; a review of the English literature revealed only 10 pediatric and 6 adult cases. Patients with pancreatitis should always be evaluated for EBV serology, even in the absence of the typical clinical and hematological features of infectious mononucleosis. For these patients, good prognosis is generally expected.

Clinical insights into drug-associated pancreatic injury

PURPOSE OF REVIEW

Drug-induced pancreatitis is one of the top three causes of acute pancreatitis. A drug exposure is traditionally determined to be the cause of pancreatitis only after other possible and common causes of pancreatitis have been excluded.

RECENT FINDINGS

In this review, we challenge this traditional notion of drug-induced pancreatitis as a diagnosis of exclusion. Instead, we propose to shift the paradigm of conceptualizing what we term drug-associated pancreatic injury (DAPI); as a continuum of pancreatic injury that can be concomitant with other risk factors. The aims of this targeted review are to harness recent literature to build a foundation for conceptualizing DAPI, to highlight specific drugs associated with DAPI, and to describe a framework for future studies of DAPI.

SUMMARY

Our hope is that probing and characterizing the mechanisms underlying the various types of DAPI will lead to safer use of the DAPI-inducing drugs by minimizing the adverse event of pancreatitis.

Acute pancreatitis in 60 Iranian children: do pediatricians follow the new guidelines in diagnosis and management of acute pancreatitis?

Background

The incidence of acute pancreatitis in children is increasing, but causes and diagnostic and therapeutic methods are various in different centers. The aim of this study was to investigate the common causes and routine diagnostic and therapeutic methods of acute pancreatitis in children in a pediatric gastrointestinal referral center and its accordance with existing guidelines.

Methods

In this retrospective, cross-sectional study, a total of 60 children with a diagnosis of acute pancreatitis, were studied.

Results

The most common causes of acute pancreatitis were systemic and metabolic diseases and medications. CT scan was performed for 36% of patients, but 31% of patients, for whom a CT scan was performed had no clear indication of CT scan. Only half of the patients received fluid 1.5 times their maintenance in the first 24 h. Antibiotic therapy was performed for 48% of patients but medical indications for antibiotic treatment were found in only 34% of cases. During the COVID-19 pandemic, the relative incidence of acute pancreatitis was increased.

Conclusions

In children with systemic and metabolic disease and using anticonvulsant drugs, it is important to consider the incidence of this disease. In clinical education, the risks of radiation due to unnecessary CT scans and inappropriate prescription of antibiotics need to be emphasized. More research should be done to study the association between COVID-19 and acute pancreatitis.

Acute Pancreatitis and Recurrent Acute Pancreatitis in Children: A 10-Year Retrospective Study

Aim

To compare the clinical characteristics of acute pancreatitis (AP) and recurrent acute pancreatitis (ARP) in children.

Method

From January 2011 to January 2021, a total of 275 pediatric patients with AP admitted to a tertiary teaching hospital were enrolled.

Results

The median age of 275 children was 12.0 years. Among them, 55 cases were ARP. The leading causes of pediatric pancreatitis were biliary tract and virus infection. The percent of male in the AP group was higher than that in the ARP group. Viral infection in the AP group were higher than that in the ARP group, but anatomical abnormalities were lower than those in the ARP group. The incidence of pancreatic pseudocysts in the ARP group was higher than that in the AP group. The median interval time from AP to ARP was 3.0 months.

Conclusion

The main causes of pediatric pancreatitis were biliary tract and virus infection in the study. AP caused by virus infection seems to be less likely to develop into ARP. Female and anatomical abnormality are risks of ARP. Children with ARP are more likely to be complicated with pancreatic pseudocyst. There was no difference in ICU admission or mortality between AP and ARP.

Etiology and classification of acute pancreatitis in children admitted to ICU using the Pediatric Sequential Organ Failure Assessment (pSOFA) score

BACKGROUND

Pediatric acute pancreatitis (AP) is rare but increasing. Severe AP is associated with higher morbidity and mortality. However, there are no universally accepted prognostic criteria for AP.

METHODS

This retrospective study included children with AP admitted to an intensive care unit (ICU) of our tertiary pediatric center between January 2009 and December 2018. The severity of organ dysfunction in AP was assessed according to the modified Atlanta criteria using the Pediatric Sequential Organ Failure Assessment (pSOFA) and Computed Tomography Severity Index (CTSI).

RESULTS

Seventy acute episodes of AP were evaluated in 55 children with primary pancreatitis. In addition, secondary AP was diagnosed in 15 patients originally admitted to ICU for different indications. Mild AP [no organ dysfunction, normal computed tomography (CT) finding] was the most prevalent (64/85 episodes in 49 children), followed by moderate AP (15 children; pSOFA 2-9 points, CTSI 3-4 points on admission). Severe AP (pSOFA 4-17 points, CTSI 6-10 points) was diagnosed in 6 children with traumatic or secondary AP. The most frequent etiologies of primary AP episodes were idiopathic (39%) and biliary (31%). Children with idiopathic AP had frequent relapses and comorbidities. Hereditary AP was typically mild, but presented with high pancreatic enzyme levels and recurrence rates. Admission at ICU and an interval without enteral nutrition (EN) were relatively short in drug-induced AP and relatively long in secondary and traumatic AP. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 13 patients with biliary AP and in 4 patients with traumatic AP. No AP-related death was observed.

CONCLUSION

pSOFA score accurately reflects the severity and prognosis of AP in children.

Risk Factors, Clinical Features, and Outcomes of Acute Pancreatitis in Children in Endemic Zone of Ascariasis in Eastern Bihar: A Hospital-Based Study

Objective

This study aims to describe the etiology, clinical features, and outcomes of acute pancreatitis (AP) in children in an endemic area of hepatobiliary ascariasis.

Methods

This retrospective observational study included acute pancreatitis (AP) patients in the age group of 2-15 years from January 2019 to January 2022. Demographic profile, risk factors, clinical features, laboratory imaging, and outcome data were collected and analyzed.

Results

A total of 40 patients comprising of 21 males (52.5%) and 19 females (47.5%) were included. The median age of the diagnosis of AP was 8.3 years (range: 4-14 years). Biliary ascariasis was the most frequent etiology of AP (n=18, 45%), followed by gallbladder (GB) stone (n=6, 12%), trauma (n=1, 2.5%), hepatitis (n=1, 2.5%), valproate drug (n=1, 2.5%), and GB sludge (n=1, 2.5%). In clinical features, all cases had pain in the abdomen (n=40, 100%), followed by fever (n=9, 22.5%), nausea/vomiting (n=33, 82.5%), jaundice (n=2, 5%), and anemia (n=2, 5%). Three (7.5%) patients developed complications such as shock, pseudocyst, and necrotizing pancreatitis, respectively. The average median hospital stay was nine days (range: 4-20 days). No mortality occurred in our study.

Conclusions

This study revealed a high prevalence (12-13 cases/year) of AP in children in this area. Biliary ascariasis (45%) emerged as the commonest risk factor. Most of the cases suffered from mild AP (92%) and so recovered completely without any complication.

Current clinical opinion on CFTR dysfunction and patient risk of pancreatitis: diagnostic and therapeutic considerations

INTRODUCTION

Cystic fibrosis transmembrane conductance regulator (CFTR)-mediated chloride and bicarbonate secretion is integral to the pancreas' ability to produce the alkaline pancreatic juice required for proper activation of enzymes for digestion. Disruption in this process increases the risk for pancreatitis.

AREAS COVERED

Using original basic and clinical research, as well as clinical case reports and recent reviews indexed in PubMed, we discuss why patients with CFTR dysfunction are at risk for pancreatitis. We also discuss diagnostic modalities for assessing CFTR function, as well as new therapeutic advancements and the impact these are having on pancreatic function, pancreatitis in particular.

EXPERT OPINION

CFTR-related pancreatitis occurs in the presence of monallelic or biallelic mutations and/or from toxin-mediated channel disruption. Research-based CFTR diagnostics have been expanded, yet all current methods rely on measuring CFTR chloride transport in non-pancreatic cells/tissue. Newer CFTR-directed therapies ('CFTR modulators') are both improving pancreatitis (pancreatic-sufficient CF patients) and increasing the risk for pancreatitis (previously pancreatic-insufficient CF patients). Our experiences with these drugs are enlightening us on how CFTR modulation can affect pancreatitis risk across a wide spectrum of pancreatic disease, and represents an opportunity for therapeutic relief from pancreatitis in those without CF, but who suffer from CFTR-related pancreatitis.

Lethal hemorrhagic necrotizing pancreatitis in a child with congenital immunodeficiency and COVID-19

Purpose

Various manifestations of coronavirus (SARS-CoV-2) have been reported since the pandemic began. Some articles have reported acute pancreatitis in adult patients due to COVID-19 infection. To our knowledge this is the first report of acute hemorrhagic necrotizing pancreatitis in children associated with SARS-CoV-2 infection.

Case presentation

A 7-year-old girl with congenital immunodeficiency was referred to the intensive care (ICU) unit with acute respiratory distress syndrome. She required mechanical ventilation (MV) due to pulmonary involvement of COVID-19 (chest CT with lower lung ground-glass opacities). SARS-CoV-2 infection was laboratory confirmed. Following a 49-day stay in the ICU, due to the clinical and radiological signs of acute abdomen and to the rapid deterioration in the clinical status, an indication to proceed an urgent surgerical intervention was made. Intra-operatively an adhesiolysis with blunt dissection of the of gastrocolic ligament was performed, then followed by debridement of the necrotic pancreas (more than 1⁄2 of the pancreas was damaged). Continuous lavage and drainage were placed. During the post-operative period, patient required aggressive MV and insulin therapy for persistent hyperglycemia. The CT scans reported a necrosis of the pancreas and we observed amylase and lipase elevation in the peritoneal lavage sample. Despite active intensive therapy, the patient's condition did not improve and she died 38 days after laparotomy as a result of multi-organ failure.

Conclusion

The mechanism for the development of acute haemorrhagic necrotizing pancreatitis in the COVID-19 positive patients is unclear; perhaps it is due to a direct cytopathic effect from the COVID-19 virus, or due to the ACE2 expression in pancreas.

Multidisciplinary Approach to the Care of Children With Acute Recurrent Pancreatitis and Chronic Pancreatitis

OBJECTIVES

The aim of this article is to provide guidance to centers and organizations on the personnel (both physician and nonphysician) needed to create and sustain an optimal team, along with potential alternatives, to provide care to children with acute recurrent pancreatitis and chronic pancreatitis.

METHODS

This document was developed in collaboration with the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Pancreas Committee and the National Pancreas Foundation (NPF) after several meetings.

RESULTS

This document highlights both physician and nonphysician personnel needed to provide multidisciplinary care to children with pancreatitis per the recommendation of the NASPGHAN Pancreas Committee members in year 2021 and added to the currently published NPF criteria. We summarize how the NPF criteria would fit with the recently published pediatric pancreatitis society articles from the NASPGHAN.

CONCLUSIONS

It is important to manage children with acute recurrent pancreatitis and chronic pancreatitis in a multidisciplinary setting. There is need to study the impact of these personnel on the outcomes of children with pancreatitis.

Digestive outcomes in Cystic fibrosis

Cystic fibrosis (CF) is the most frequent life-limiting autosomal recessive disease in Caucasians, affecting the respiratory tract, but also the pancreas, gut, and hepatobiliary tract. CF is caused by variants in the Cystic Fibrosis Transmembrane conductance Regulator (CFTR) gene. Prognosis of CF has markedly improved over the last 20 years because of the management in CF centers and recent introduction of CFTR modulators, aimed at correcting the defective CFTR protein. There are nowadays more CF adults than children, with a predicted median survival age of around 50 years in high-income countries. Around 85% of CF patients have pancreatic insufficiency present at birth. Gastroesophageal reflux disease (GERD) is more frequent in CF patients, but its role on decline in lung health is controversial. Distal small bowel obstruction syndrome (DIOS) caused by meconium-like stool plugs occurs at any age after the neonatal period, affecting up to 15-20% of CF patients. Because of increased life expectancy, most CF patients are expected to live to their fifties or beyond, when cancer is more frequent. In addition, CF is associated with a higher risk for GI malignancy as compared with the general population. Colorectal cancer represents the most significant risk, and colonoscopy-based screening is recommended from 40 years of age onwards. Other digestive outcomes in CF reviewed in this paper include meconium ileus, Clostridium difficile infection, intussusception, acute appendicitis, small intestinal bacterial overgrowth, appendiceal mucocele and rectal prolapse. Every CF Center should comprise a gastroenterologist with expertise in the care of CF patients.

Predictors of Glycemic Outcomes at 1 Year Following Pediatric Total Pancreatectomy With Islet Autotransplantation

OBJECTIVE

Total pancreatectomy with islet autotransplantation (TPIAT) is indicated to alleviate debilitating pancreas-related pain and mitigate diabetes in patients with acute recurrent and chronic pancreatitis when medical/endoscopic therapies fail. Our aim was to evaluate predictors of insulin requirement at 1 year following TPIAT in a cohort of children.

RESEARCH DESIGN AND METHODS

This was a review of 43 pediatric patients followed after TPIAT for 1 year or longer. Primary outcome was insulin use at 1 year, categorized as follows: insulin independent, low insulin requirement (<0.5 units/kg/day), or high insulin requirement (≥0.5 units/kg/day).

RESULTS

At 1 year after TPIAT, 12 of 41 (29%) patients were insulin independent and 21 of 41 (51%) had low and 8 of 41 (20%) had high insulin requirement. Insulin-independent patients were younger than those with low and high insulin requirement (median age 8.2 vs. 14.6 vs. 13.1 years, respectively; P = 0.03). Patients with insulin independence had a higher number of transplanted islet equivalents (IEQ) per kilogram body weight (P = 0.03) and smaller body surface area (P = 0.02), compared with those with insulin dependence. Preoperative exocrine insufficiency was associated with high insulin requirement (P = 0.03). Higher peak C-peptide measured by stimulated mixed-meal tolerance testing (MMTT) at 3 and 6 months post-TPIAT was predictive of lower insulin requirement at 1 year (P = 0.006 and 0.03, respectively).

CONCLUSIONS

We conclude that insulin independence following pediatric TPIAT is multifactorial and associated with younger age, higher IEQ per kilogram body weight transplanted, and smaller body surface area at time of operation. Higher peak C-peptide measured by MMTT following TPIAT confers a higher likelihood of low insulin requirement.

Risk factors for the progression from acute recurrent to chronic pancreatitis among children in China

BACKGROUND

Risk factors for progression from acute recurrent pancreatitis (ARP) to chronic pancreatitis (CP) in children are poorly understood.

AIM

To summarize the clinical characteristics of children with ARP and CP, identify the risk factors of CP, and investigate the factors associated with rapid progression from initial onset of ARP to CP.

METHODS

The following variables were included in the risk factor analysis: sex, age at onset, family history, pancreas or biliary tract structural abnormalities, and genetic variations. Univariate and multivariate logistic regression analyses were used to assess the risk factors of CP. The Kaplan-Meier curves of the ARP progression to CP for various risk factor groupings were constructed and compared using the log-rank test. The Cox proportional hazard regression model was fitted to estimate the hazard ratio (HR) of progression to CP for each risk variable.

RESULTS

In total, 276 children were studied, of whom 136 progressed to CP. Among them, 41 had pancreatic duct obstructive disease; 105 underwent genetic testing, of whom 68 were found to have genetic variations. Among the remaining 140 patients who did not progress to CP, 61 had biliary obstructions. Forty-three of these children underwent genetic testing, and 15 were found to have genetic variations. Risk factor analysis showed that children with gene mutations were at a higher risk of progressing to CP [odds ratio (OR) = 3.482; 95% confidence interval (CI): 1.444-8.398; P = 0.005]; children with pancreas divisum (PD) had a higher risk of CP than those without (OR = 8.665; 95% CI: 1.884, 9.851; P = 0.006). Further, children whose first ARP occurred at an older age might develop CP faster (HR = 1.070; 95% CI: 1.003, 1.141; P = 0.039). Children with gene mutations had a faster rate of progression to CP after onset than children without gene mutations (HR = 1.607; 95% CI: 1.024, 2.522; P = 0.039), PRSS1 gene mutations were more associated (P = 0.025). There was no difference in the rate of progression from ARP to CP in children with PD (P = 0.887); however, endoscopic retrograde cholangiopancreatography (ERCP) intervention delayed the progression to CP in ARP patients with PD (P = 0.033).

CONCLUSION

PRSS1 gene mutations and PD are key risk factors for ARP progression to CP in children. PD itself does not affect the disease progression rate, but therapeutic ERCP can be beneficial to patients with ARP with symptomatic PD and delay the progression to CP.

Etiology and outcome of acute recurrent pancreatitis and chronic pancreatitis

BACKGROUND

Owing to the lack of data, we aimed to determine the etiology and outcome of acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) in children in Southeast Asia.

METHODS

This retrospective study was conducted at a university hospital in Bangkok, Thailand. We included patients aged <18 years who were diagnosed with pancreatitis from 2000 to 2021.

RESULTS

Among 155 patients with pancreatitis, 21 (13.5%) were diagnosed with either ARP (n = 7) or CP (n = 14). Clinical manifestations of CP included chronic abdominal pain (n = 10, 71.4%), steatorrhea (n = 8, 57.1%), and diabetes mellitus (n = 1, 7.1%). Positive radiological findings compatible with CP were detected from an abdominal ultrasound, computed tomography, magnetic resonance cholangiopancreatography in 70%, 90.9%, and 92.9% of patients, respectively. Genetic, metabolic, and pancreaticobiliary causes were the major causes of ARP/CP (23.8% each) and the etiologies were unidentified in one-fifth of the patients. Patients with metabolic diseases who had AP were at-risk of developing ARP (hazards ratio [HR], 4.7, 95% confidence interval [CI]: 1.5-13.9). Children with ARP or CP were younger than those with AP (P = 0.04). Approximately two-thirds of patients with CP had growth faltering and they had more episodes of hospitalization due to acute attacks when compared to patients with ARP ( 4 [interquartile range [IQR], 3-6] vs. 3 [IQR, 2-3]; P = 0.02).

CONCLUSION

Genetic, metabolic, and pancreaticobiliary diseases were the common etiologies of ARP and CP among children living in a developing country in Southeast Asia. The burden of CP included malnutrition and frequent hospitalization. The findings emphasize the importance of an early etiological diagnosis and monitoring for pancreatic insufficiency in ARP/CP.

Etiology, case fatality, recurrence, and severity in pediatric acute pancreatitis: a meta-analysis of 48 studies

For children, there are very few published reviews focusing on severe acute pancreatitis (AP). PubMed, EMBASE, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, EBSCO, and Cochrane Library were searched from inception until March 2020. Meta-regression analyses were used to estimate the etiology, case fatality, recurrence, and severity of pediatric AP in different regions (North America, Asia, South America, Europe, and Oceania). Pooled data from 47 papers (48 studies) found that main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate (CFR) of pediatric AP is 4.7% (North America), 6.2% (Europe), 2.4% (Asia), 3.1% (South America), and 7.4% (Oceania). The incidence rates of recurrent acute pancreatitis (RAP) in children who have had an episode of acute pancreatitis in North American, Asia, and Europe were 15.3, 13.1, and 13.8%, respectively. The incidence of severe acute pancreatitis (SAP) in different regions was 30.3% (Oceania), 29.2% (South America), 20.8% (Europe), 15.8% (Asia), and 13.7% (North America). It suggests that physicians should notice the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage. IMPACT: It indicates the etiology of pediatric acute pancreatitis for the initial assessment, diagnosis, and prediction of relapse. Main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate of pediatric AP is diverse worldwide. It suggests that physicians noticed the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage.

Pancreatitis in Children

Pediatric pancreatitis describes a spectrum covering acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis, each with varying clinical manifestations and risk factors requiring a tailored diagnostic approach. We emphasize management strategies based on age, risk factors, recurrence, and complications. A discussion of the role of therapeutic endoscopy is reviewed and highlights the growing role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in children with pancreatitis. Particular diagnostic challenges in autoimmune pancreatitis are reviewed with an emphasis on differentiating this entity from alternate pancreaticobiliary pathologies. Finally, we explore a multidisciplinary approach to acute recurrent and chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in children

Gastrointestinal endoscopy is fundamental to diagnostic and therapeutic procedures in pediatric gastroenterology. In the decades since endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) for hepatobiliary and pancreatic disease were introduced into clinical practice, there has been increasing interest in these procedures, and practice guidelines and position papers that clearly define the role of ERCP and EUS in children have been published. Based on the distinction of endoscopy between children and adults, this review focuses on the current state of ERCP and EUS procedures in children, including the types of endoscopes used in children, general anesthesia and radiation exposure, biliary and pancreatic indications, considerations of education and training for ERCP and EUS procedures in children, and expectations for development of endoscopes for children.

Acute pancreatitis in children: a review with clinical perspectives to enhance imaging interpretation

Pediatric acute pancreatitis has distinct etiologic, clinical and prognostic characteristics in contrast to the adult form of the disease. This review offers a comprehensive imaging update that emphasizes the importance of recognizing specific findings that are relevant from the clinical standpoint. Knowledge of these features facilitates communication among multidisciplinary team members and ultimately could lead to the improved care of pediatric acute pancreatitis patients.