How to investigate recurrent pancreatitis in a child?

Diagnostic Approach to Recurrent Pancreatitis in Children

Endoscopic ultrasound (EUS) should be the first advanced diagnostic test for children with recurrent pancreatitis after initial evaluation has failed to identify an etiology. 1

Initial Evaluation

• Obtain comprehensive personal and family history focusing on:

  • Family history of pancreatitis (suggesting hereditary causes) 2, 3
  • Medication use that could trigger pancreatitis 1
  • Previous abdominal trauma 3
  • Symptoms of viral illness (suggesting viral etiology) 4

• Laboratory testing should include:

  • Liver biochemistries (ALT, AST, bilirubin) to identify biliary causes 4, 1
  • Serum triglycerides and calcium levels to identify metabolic causes 4, 1
  • Amylase and lipase to confirm diagnosis 5

• Initial imaging:

  • Abdominal ultrasound to evaluate for gallstones 4, 1
  • Repeat ultrasound if initially negative, as gallstones may be missed on first examination 1

Advanced Diagnostic Evaluation

• Endoscopic ultrasound (EUS) is the preferred diagnostic test for unexplained recurrent pancreatitis in children 4, 1

  • EUS can detect microlithiasis, pancreatic tumors, and anatomical variations such as pancreas divisum 1
  • Consider delaying EUS for 2-6 weeks after an acute episode to avoid interference from inflammatory changes 4

• MRI with MRCP (magnetic resonance cholangiopancreatography):

  • Complementary or alternative to EUS based on local expertise and availability 4, 1
  • Particularly helpful in identifying pancreatic ductal abnormalities and anatomical variants 4
  • Consider secretin-enhanced MRCP where available for improved diagnostic yield 4

• Contrast-enhanced CT scan:

  • Indicated to exclude pancreatic tumors, especially in older children 4, 1
  • Should be performed between 3-10 days after admission in severe cases 4

Specific Etiologies to Investigate

• Genetic testing should be considered for:

  • Children with family history of pancreatitis 2, 3
  • Early-onset recurrent pancreatitis without obvious cause 2
  • Testing for PRSS1, SPINK1, CFTR, and CTRC mutations 2

• Anatomical abnormalities:

  • Pancreas divisum (most common congenital pancreatic anomaly) 4, 3
  • Other ductal anomalies that may require ERCP for diagnosis 4

• Metabolic causes:

  • Hypertriglyceridemia (levels >5.65 mmol/L) 3
  • Hypercalcemia 1, 3

• Autoimmune pancreatitis:

  • Consider in children with IgG4-related disease 2
  • May require specialized testing and imaging 2

Role of ERCP

• ERCP should not be performed routinely for diagnostic purposes alone due to its associated risks 1
• ERCP is indicated in specific situations:
  • Presence of jaundice or dilated common bile duct 4
  • Recurrent attacks when other diagnostic modalities are non-diagnostic 4, 1
  • When therapeutic intervention is anticipated (e.g., stone removal, stenting) 1, 6
  • To evaluate for anatomical variations like pancreas divisum in recurrent cases 4

Important Considerations

• The etiology of pancreatitis should be determined in 75-80% of cases; no more than 20-25% should remain classified as "idiopathic" 4, 1
• Children with recurrent pancreatitis are at risk for progression to chronic pancreatitis with complications including:
  • Exocrine pancreatic insufficiency (occurs in about 25% of children with chronic pancreatitis) 7
  • Endocrine insufficiency/diabetes (occurs in about 6% of children) 7
  • Malnutrition and poor bone density 7

Pitfalls to Avoid

• Do not label pancreatitis as "idiopathic" prematurely; thorough evaluation should identify a cause in most cases 1
• Avoid routine ERCP in children with a single mild attack without jaundice or bile duct dilation 1
• Do not rely solely on initial imaging; repeated investigations often increase the likelihood of identifying an etiology 1
• Remember that one out of every three children with acute pancreatitis may develop recurrences, so follow-up is essential 3