Sonographic findings of pancreatitis in children

Enlargement of the Pancreas in Children Diagnosed with Acute Pancreatitis: An Approach Based on P/V Ratio

Background Acute pancreatitis is a reversible inflammation of the pancreatic parenchyma. Enlargement of the pancreas is often envisaged in such conditions. This study evaluates P/V ratio, as a marker to decide pancreatic enlargement in disease condition.

Purpose The aim of this study was to develop imaging-based diagnostic criterion for acute pancreatitis in children based on P/V ratio.

Material and Methods This study included 37 children with acute pancreatitis and 283 children asymptomatic for pancreatic disorders, from a single hospital center. The age of children ranged between 2 and 18 years. P/V ratio, which is the ratio of greatest anteroposterior dimension of the head, body, and tail of the pancreas relative to the transverse lumbar vertebral body, was obtained for each child through ultrasonographic examination. Age-adjusted receiver operating characteristics (AROC) analysis was performed on P/V ratio at presentation for each pancreatic region, and the sensitivity at 90% specificity, the threshold errors, and the corresponding cutoffs were obtained. The enlargement assessment was also done after clinical recovery by referring to the cutoffs of respective regions.

Results AROC analysis for males and females resulted into a maximum sensitivity of 83.33 and 81.67%, respectively, at 90% specificity for head. The error thresholds for both the groups were same, i.e., 0.098, indicating that 90% of the observations had errors less than the threshold. The corresponding P/V ratio cutoff for males and females was 0.43 and 0.42, respectively.

Conclusion Radiologists and clinicians can refer a cutoff value of 0.4 for each region, along with hypoechogenicity, to decide about enlargement of the pancreas in acute pancreatitis condition.

Reporting Standards for Chronic Pancreatitis by Using CT, MRI, and MR Cholangiopancreatography: The Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer

Chronic pancreatitis is an inflammatory condition of the pancreas with clinical manifestations ranging from abdominal pain, acute pancreatitis, exocrine and/or endocrine dysfunction, and pancreatic cancer. There is a need for longitudinal studies in well-phenotyped patients to ascertain the utility of cross-sectional imaging findings of chronic pancreatitis for diagnosis and assessment of disease severity. CT and MR cholangiopancreatography are the most common cross-sectional imaging studies performed for the evaluation of chronic pancreatitis. Currently, there are no universal reporting standards for chronic pancreatitis. Several features of chronic pancreatitis are applied clinically, such as calcifications, parenchymal T1 signal changes, focal or diffuse gland atrophy, or irregular contour of the gland. Such findings have not been incorporated into standardized diagnostic criteria. There is also lack of consensus on quantification of disease severity in chronic pancreatitis, other than by using ductal features alone as described in the Cambridge classification. The Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer (CPDPC) was established by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Cancer Institute in 2015 to undertake collaborative studies on chronic pancreatitis, diabetes mellitus, and pancreatic adenocarcinoma. CPDPC investigators from the Adult Chronic Pancreatitis Working Group were tasked with development of a new consensus approach to reporting features of chronic pancreatitis aimed to standardize diagnosis and assessment of disease severity for clinical trials. This consensus statement presents and defines features of chronic pancreatitis along with recommended reporting metrics. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Megibow in this issue.

Acute pancreatitis and cholecystitis associated with postpartum HELLP syndrome: a case and review

We report a case of preeclampsia associated with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome and concomitant nonbiliary acute pancreatitis and cholecystitis in the first postpartum day. A thorough investigation ruled out known etiologies of both pancreatitis and cholecystitis. Following conservative treatment, the patient's HELLP syndrome, pancreatitis, and cholecystitis resolved on the third postpartum day. Preeclampsia is associated with microvascular abnormalities that may involve the splanchnic circulation. These abnormalities may cause not only HELLP syndrome but also pancreatitis and cholecystitis. Recognizing that ischemia can damage not only the liver but also the pancreas and gallbladder, could result in improvements in the diagnosis and management of pancreatitis in patients with preeclampsia.

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.

Ascites in the puerperium: a missed diagnosis of acute postpartum pancreatitis

INTRODUCTION

Acute pancreatitis in pregnancy is often associated with severe morbidity. It is usually an antepartum problem occurring in late pregnancy. It rarely occurs in the postpartum period and when it does diagnosis can be difficult.

CASE REPORT

We report a case of 'unexplained' ascites following ventouse delivery, diagnosed 6 weeks later as acute pancreatitis.

CONCLUSION

Although it is rare, acute pancreatitis must be considered when evaluating patients presenting with abdominal pain and/or ascites in the postpartum period. Serum amylase may not always be elevated and early recourse to CT scan will facilitate diagnosis and allow for appropriate management.

[Pancreatitis: review of our casuistics in the last 10 years]

OBJECTIVE

Pancreatitis is a rare cause of abdominal pain in childhood. Advances in imaging techniques for pancreatic disease have enabled earlier clinical and etiological diagnosis, thus improving treatment possibilities. The aim of this study was to analyze the etiology, diagnostic methods, and management in patients with pancreatitis diagnosed in our hospital in the last 10 years.

MATERIAL AND METHODS

We reviewed the children aged 0-16 years with a diagnosis of pancreatitis admitted to our hospital between 1990 and 2000. Diagnostic criteria were symptoms suggestive of pancreatitis and hyperamylasemia.

RESULTS

There were 8 females and 1 male. The median age was 11.5 years (range: 7-16 years). Laboratory findings were as follows: mean amylase level was 1601 U/l and mean lipase level was 506 U/l. Imaging tests: ultrasonography, abdominal computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) were performed in 1 patient, and magnetic resonance cholangiopancreatography (MRCP) was performed in 2. Etiology was cholelithiasis (2 patients), secondary to anti-oncological therapy (3 patients), hypercholesterolemia (1 patient), and idiopathic (3 patients). Medical treatment consisted of diet, analgesia, and octreotide in 1 patient, and antioxidants in 1 patient. Surgery was required in 2 patients. Complications consisted of pancreatic pseudocyst in 2 patients.

CONCLUSIONS

The incidence of childhood pancreatitis is low. In our series, mainly teenage girls were affected. The main causes were idiopathic and toxic. Diagnosis was given by elevated amylase and lipase levels in blood and by imaging tests (ultrasonography, abdominal CT, ERCP, MRCP, depending on the patient). Basic treatment consisted of support measures (fasting and analgesia) together with octreotide, antioxidants or surgical treatment, depending on etiology.

Epigastric pain and sonographic assessment of the pancreas in dengue hemorrhagic fever

PURPOSE

This study reports the sonographic features of the pancreas in children who have dengue hemorrhagic fever (DHF) with epigastric pain, evaluates pancreatic abnormalities as the source of this pain, and relates sonographic findings, DHF status, and serum levels of amylase and lipase.

METHODS

Over 3.5 years, real-time sonographic examination of the pancreas was prospectively performed in 148 children (age range, 5 months-14 years) who had DHF with epigastric pain. The DHF diagnosis was confirmed by serologic examination and viral isolation.

RESULTS

Of the 142 children included in this study, 72 had mild DHF (grade I or II) and 70 had severe DHF (grade III or IV). An enlarged pancreas was found in 41 patients (29%), 10 (14%) of whom had mild DHF and 31 (44%) of whom had severe DHF. The pancreas was hyperechoic relative to the liver in 36 patients (25%), isoechoic in 98 (69%), and hypoechoic in 8 (6%).

CONCLUSIONS

The majority of patients with DHF and epigastric pain do not have an enlarged pancreas, different echogenicity of the pancreas compared with the liver, or a dilated pancreatic duct. Thus, pathologic changes of the pancreas cannot be the only cause of epigastric pain in DHF patients. Increased serum levels of amylase and lipase are commonly seen in patients with severe DHF and an enlarged pancreas.

Influence of severe underlying pathology and hypovolemic shock on the development of acute pancreatitis in children

Acute pancreatitis in children is a little known and poorly defined disease, and thus rarely considered in the diagnosis of pediatric abdominal pain. In the past 14 years, the authors treated 21 children who had acute pancreatitis. Trauma was the cause of the disease in 29% of the patients. One third (33%) had hypovolemic shock-related pancreatitis (mostly after either cardiopulmonary bypass or severe gastrointestinal bleeding). Furthermore, a major proportion (38%) had severe underlying organic disease. The clinical presentation was unremarkable; most patients (83%) had abdominal pain, especially in the epigastrium, and vomiting was the only other clinical sign exhibited by more than 50%. The Glasgow score (a severity grading system based on eight laboratory values and calculated within the first 48 hours after admission) had good specificity but poor sensitivity. Amylasemia had no predictive value. More than half our patients (57%) had complications, mainly pseudocysts (24%) and relapse (14%), and about one quarter (24%) had severe pancreatitis. There were two deaths (10%), and all surviving children (90%) eventually were symptom-free. Treatment was conservative in the majority of cases; eight patients (38%) required surgery. Hypovolemic shock and a severe underlying pathology were identified as risk factors for the occurrence of severe pancreatitis (P < .005) or death (P < .001), but not for the development of complications.

Pancreatitis in children--experience with 43 cases

Pancreatitis in children is not common and can be associated with severe morbidity and mortality. We encountered 43 children, ranging in age from 2 to 18 years, with pancreatitis over the past 10 years. The diagnosis of pancreatitis was made in those patients who showed: (1) significant intra-operative pathology or; (2) clinical findings of pancreatic inflammation and laboratory confirmation. More than one third (16 cases) of the cases were due to trauma, other causes included systemic disease (10), structural disease (8), and toxins or drugs (4). Five cases were classified as idiopathic. Most of the patients presented with abdominal pain (95%) and vomiting (56%). Jaundice was found in 7 patients and an abdominal mass in 2. Morbidity included pseudocyst (10), relapse (4), hyperglycaemia (4) and miscellaneous problems. Eight (50%) of the patients with trauma and 6 (86%) of the patients with structural diseases required surgery. Other patients were managed conservatively with bowel rest, gastric decompression, intravenous fluid and total parenteral nutrition. One case had a fatal outcome. All the survivors did well in long term follow up. Relevant literature has been reviewed and the sensitivity of various diagnostic modalities compared and discussed. A lesser known association between pancreatitis and structural anomalies such as choledochal cyst is discussed. To our knowledge, the present review is the first on pancreatitis in Chinese children.

CONCLUSION

Pancreatitis can occur from a wide variety of causes and may result in severe complications. Early diagnosis, close monitoring and aggressive intervention are mandatory to reduce morbidity and mortality.

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.

Shwachman-Diamond syndrome: clinical, radiological and sonographic findings

Six children with Shwachman-Diamond syndrome have been diagnosed and treated in our hospital since 1986. We describe the radiological and sonographic findings of this rare disease, which is characterized by metaphyseal chondrodysplasia, neutropenia and exocrine pancreatic insufficiency. It presents with varying extremity shortening, "cup" deformation of the ribs, metaphyseal widening and hypoplasia of the iliac bones, as well as increased echogenicity of the normalized pancreas. We discuss the differential diagnosis and review the literature.

Shwachman-Diamond syndrome: clinical, radiological and sonographic aspects

Six children with Shwachman-Diamond syndrome have been diagnosed and treated in our hospital since 1986. We describe the radiological and sonographic findings of this rare disease which is characterized by metaphyseal chondrodysplasia, neutropenia and pancreatic exocrine insufficiency. It presents with variable extremity shortening, "cup" deformation of the ribs, metaphyseal widening and hypoplasia of the iliac bones, and increased echogenicity of the pancreas without change in size. We discuss the differential diagnosis and review the literature.

Acute chemical pancreatitis associated with carbamazepine intoxication

A 5-year-old mentally retarded child developed laboratory evidence of pancreatitis during accidental acute carbamazepine (CBZ) intoxication. He had been seizure-free with CBZ for 4 years for a seizure disorder with no obvious toxicity. CBZ had been discontinued 5 months before he was admitted to the hospital. After he accidentally ingested a CBZ overdose, he was found vomiting and lethargic. Serum amylase and lipase levels were increased for several days. With supportive treatment and no CBZ, he recovered and serum amylase and lipase levels returned to normal. No other causes of pancreatitis were identified. Therefore, most likely the chemical pancreatitis was associated with the acute CBZ intoxication.

Percutaneous transgastric drainage of the lesser sac in children

In four children (5-14 years old), lesser sac fluid collections (3 pseudocysts and 1 abscess) were externally drained using a percutaneous transgastric approach. With ultrasound or CT guidance and fluoroscopic monitoring, a sheathed needle is inserted through the stomach into the lesser sac fluid collection, the catheter is exchanged, secured in place and connected to external drainage. All four fluid collections were complications of pancreatitis (3 acute post-traumatic, 1 post-surgical). All four fluid collections were successfully drained without need for surgical intervention. There were no major complications. Three minor complications occurred as a result of reinsertion of catheters: transient gastric venous bleeding, hematuria, and bleeding into the pseudocyst. Percutaneous transgastric drainage can be performed successfully in children, and provides an alternative to surgical intervention of lesser sac fluid collections. Drainage early in the course of pancreatic pseudocysts may lessen the morbidity, potential mortality, and prolonged hospitalization usually necessary for standard medical and surgical management of these patients.

Pancreatic echogenicity in premature and newborn infants

Little information is available regarding pancreatic echogenicity in premature infants and neonates. We prospectively studied 65 patients (30 premature infants and 35 neonates) and compared pancreatic echogenicity to a control group of 25 infants and 35 older children. Pancreatic echogenicity was graded relative to hepatic echogenicity measured at a similar depth. In the premature infants and neonates the initial ultrasounds were hyperechoic in 71% compared to 5% in both control groups. Follow up ultrasounds were obtained in 73% of the premature infants and 17% of the neonates. The pancreatic echogenicity became isoechoic in 14 of 19 premature infants and 3 of 4 neonates in whom the initial ultrasound was hyperechoic. We conclude that the normal pancreatic echogenicity in premature infants and neonates is usually hyperechoic relative to liver. Pancreatic hyperechogenicity in premature infants and neonates is not necessarily indicative of disease.

Pancreatic disorders in infancy and childhood: experience with 92 cases

Ninety-two children with pancreatic disorders were treated over a 10-year period. Thirty-three had blunt trauma, while 69 had medical, metabolic, or neoplastic diseases. Children with trauma had either duct disruption (3), gland fracture (4), or pseudocysts formation (26). Operation was required in 30. Pseudocysts were treated with observation alone in three cases, ultrasound-guided percutaneous aspiration in three, surgical external drainage in two, distal pancreatectomy in four, cyst gastrostomy in ten, and cyst-Roux-en-Y jejunostomy in six. Other disorders included pancreatitis (44), neoplasms (10), nesidioblastosis (4), and pancreaticosplenic abscess (2). Treatment for neoplasms included surgical excision in nine and biopsy in one (adenocarcinoma). Patients with nesidioblastosis underwent 95% (near total) pancreatic resection (two after previous unsuccessful 80% resection). Pancreatitis was familial in two cases, necrotizing in two, idiopathic in 11, and secondary to medications in six cases (steroids, 2; L-asparaginase, 4), gallstones in 17, and choledochal cysts in 6. Pancreatitis resolved after observation and conservative therapy in ten idiopathic cases, 4/6 medication-related cases, and following correction of biliary tract disease (15/17) or choledochal cysts (6). Pancreatic resection or drainage was required in the remaining cases. Pancreatic disorders can be accurately detected with computed tomography (CT) scan in most cases (excluding insulinoma). Ultrasound (US) is useful in cases of biliary tract disease and pseudocyst formation. Traumatic pseudocysts can resolve spontaneously or with US-guided percutaneous drainage (in the presence of normal ducts). Children with neoplasms, abnormal pancreatic ducts, or recurrent pancreatitis require resection or appropriate drainage procedures. Overall survival was 95%.

Blunt injury to the pancreas in children: selective management based on ultrasound

Twenty-one children with blunt injuries to the pancreas were treated over a 5-year period. Group I consisted of 12 patients brought to our hospital within 24 hours of injury. Group II included nine patients who were referred to us more than 24 hours after injury following initial treatment at another hospital. Two group I patients died within four hours of admission from other causes. Three had early laparotomy for other injuries. Of these, two had a contusion and one had a complete transection of the pancreas. All recovered uneventfully after appropriate surgical treatment. The remaining seven were all treated nonoperatively. Two had obstructive pancreatitis secondary to duodenal hematomas, three had pancreatic contusions, and two developed pancreatic pseudocysts. All seven recovered completely without operation. In group II, three patients had undergone laparotomy elsewhere. All three had pancreatic contusions. However, only one had appropriate drainage of the injured pancreas; he recovered uneventfully. Two, who were not drained, developed pseudocysts and one of these required surgical drainage by cystgastrostomy. The other six patients in group II presented to our hospital with established pseudocysts. Three of these resolved with nonoperative treatment but three required drainage. Overall, six of ten posttraumatic pancreatic pseudocysts resolved without surgical treatment. The single most useful diagnostic test in the management of these patients was abdominal ultrasound (US). US revealed specific anatomic lesions of the pancreas--contusion, obstructive pancreatitis, or pseudocyst--and provided an objective guide to management. Surgical intervention is not necessary in all cases of pancreatic trauma.

The increased echogenicity of the pancreas in infants and children: the white pancreas

An increased echogenicity of the pancreas ("white pancreas") was sonographically found in 25 children with various pancreatic and systemic diseases. Fifteen patients with cystic fibrosis had a small white pancreas. Five patients with haemosiderosis, two with pancreatitis and one with Shwachman-syndrome presented with a normal-sized or slightly enlarged pancreas. Fatty infiltration and calcifications of the pancreas can also increase its echogenicity.

Hemorrhagic pancreatitis in a young child following valproic acid therapy. Clinical and ultrasonic assessment

Hemorrhagic pancreatitis was diagnosed with portable realtime ultrasound in a critically ill 4-year-old child. The ultrasonic features were diffuse pancreatic enlargement, generally and focally increased pancreatic echogenicity, and ascites. Ultrasound was indispensable as a portable noninvasive imaging modality that allowed for rapid and accurate diagnosis.

Use of ERCP to identify the site of traumatic injuries of the main pancreatic duct in children

Major pancreatic injuries in children are uncommon but potentially very serious. They usually occur in active young boys following characteristic accidents. Despite this they frequently go unrecognized for prolonged periods. Four patients with delayed recognition of blunt pancreatic trauma are described. The presence of pancreatic injury was identified by hyperamylasaemia in every case. Ultrasound and CT scanning were helpful in identifying pseudocysts but accurate pre-operative diagnosis of main duct disruption required endoscopic retrograde cholangiopancreatography (ERCP). Surgical treatment involved a full exploration of the lesser sac with drainage of the cyst contents and identification of the site of extravasation. Two patients with proximal duct lacerations were treated by internal drainage into a Roux-en-Y loop with the addition of a distal pancreaticojejunostomy in one case. Two patients with distal lacerations were treated by distal pancreatectomy and oversewing of the remnant. All four patients recovered and were well at follow-up. Early ERCP is the only reliable method of identifying duct injuries which require urgent surgery. It should be considered in all children with blunt pancreatic trauma.

Diagnostic imaging in children with acute chest and abdominal disorders

The authors review the imaging techniques currently used to study some of the more common emergency medical and surgical problems that are encountered in children and that are not covered elsewhere in this volume.

Pancreatic sonography: past and present

Prior to the advent of cross-sectional imaging, the diagnosis of pancreatic disease and its extent could not be obtained without surgery. Ultrasound is a noninvasive modality which has been evolving over the last 7-10 years. The purpose of this review will be to determine the present status of ultrasound in the evaluation of adult and pediatric pancreatic disease. Also, its role with regard to computed tomography (CT) and interventional techniques will be discussed.