What are the causes and treatment options for acute pancreatitis in adolescents?

Causes of Acute Pancreatitis in Adolescents

In adolescents, the most common causes of acute pancreatitis are biliary disease (gallstones), medications, trauma, systemic illness, and structural/genetic abnormalities, with biliary disease and medications being the leading etiologies in this age group. 1

Primary Etiologies

Biliary Disease

• Gallstones and choledocholithiasis are among the most frequent causes in adolescents, requiring abdominal ultrasound at admission to detect these conditions 2
• All patients with biliary pancreatitis require definitive management of gallstones during the same hospitalization to prevent recurrence 3, 2

Medications

• Drug-induced pancreatitis is a common cause in the pediatric population 1
• A thorough medication history is essential, including prescription drugs, over-the-counter medications, and supplements 1

Trauma

• Blunt abdominal trauma from sports injuries, motor vehicle accidents, or child abuse can cause pancreatic injury leading to pancreatitis 1
• This is particularly relevant in the adolescent population given their activity levels 4

Metabolic Causes

• Hypertriglyceridemia should be evaluated with serum triglyceride levels at presentation 2
• Hypercalcemia must be assessed as it can trigger pancreatitis 2

Structural and Genetic Abnormalities

• Pancreatic divisum, annular pancreas, and choledochal cysts can predispose to recurrent episodes 1
• Genetic mutations (PRSS1, SPINK1, CFTR) may be identified in cases of recurrent or idiopathic pancreatitis 4

Systemic Illness

• Viral infections (mumps, Epstein-Barr virus, coxsackievirus) can trigger pancreatitis 1
• Autoimmune conditions should be considered in the differential 4

Diagnostic Approach

The diagnosis must be established within the first 48 hours of admission, and etiology should be determined in at least 80% of cases 2

Initial Laboratory Evaluation

• Serum amylase or lipase (at least 3 times upper limit of normal for diagnosis) 3, 2
• Triglycerides, calcium, and liver function tests (bilirubin, AST, ALT, alkaline phosphatase) 2
• These tests help identify both the diagnosis and potential underlying causes 2

Imaging Studies

• Abdominal ultrasound should be performed at admission to detect gallstones or bile duct stones 2
• CT imaging is reserved for patients with persistent organ failure, signs of sepsis, or clinical deterioration 6-10 days after onset 3, 2

Treatment Principles

Fluid Resuscitation

Early aggressive fluid resuscitation with isotonic crystalloids is fundamental to optimize tissue perfusion and prevent organ failure 3, 2

• Guided by frequent reassessment of hemodynamic status 3, 2
• Avoid fluid overload while ensuring adequate perfusion 2
• This is crucial as early resolution of organ failure is associated with very low mortality 5

Pain Management

• Multimodal analgesia is a clinical priority 3, 2
• Avoid NSAIDs in patients with renal impairment or acute kidney injury 3, 2
• Adequate pain control improves patient comfort and outcomes 2

Nutritional Support

Mild to Moderate Pancreatitis

• Aggressive nutritional support is not required for mild-to-moderate disease 5
• Fasting for 2-5 days with IV fluid and electrolyte replacement 5
• Refeeding with carbohydrate-rich diet, moderate protein, and moderate fat over 3-7 days 5

Severe Pancreatitis

• Early enteral nutrition within 24-48 hours is recommended rather than keeping patients NPO 3
• Nasogastric feeding is safe and effective in approximately 80% of cases 2
• Enteral feeding decreases nosocomial infections, reduces SIRS duration, and decreases overall disease severity 5
• Parenteral nutrition should be avoided but partial parenteral nutrition can be considered if enteral route is not fully tolerated 2

Antibiotic Management

Routine prophylactic antibiotics are not recommended, even in predicted severe pancreatitis 3

• Reserve antibiotics for specific documented infections (respiratory, urinary, biliary, or catheter-related) 3
• When pancreatic necrosis infection is suspected or confirmed, use antibiotics with good pancreatic penetration (carbapenems, quinolones, or piperacillin/tazobactam) 3
• The evidence for prophylactic antibiotics remains controversial despite some studies showing benefit 5

Specific Drug Therapy

There is no proven specific drug therapy for acute pancreatitis 5

• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents (lexipafant) have all proven disappointing in large randomized studies 5

Management of Biliary Pancreatitis

ERCP Indications

• Urgent ERCP (within 24 hours) is required for patients with biliary pancreatitis and concomitant cholangitis 2
• Early ERCP (within 72 hours) should be performed in those with high suspicion of persistent common bile duct stone 2
• Definitive management of gallstones must occur during the same hospitalization 3, 2

Severity Assessment and Monitoring

Severity stratification must be performed in all patients within 48 hours of diagnosis 2

• Monitor for organ dysfunction and complications, particularly in the first week 3
• Oxygen saturation should be monitored continuously with supplemental oxygen to maintain saturation >95% 5
• Severity assessment should be repeated as the condition can evolve rapidly 6

Specialized Care Requirements

Every hospital receiving acute admissions should have a designated clinical team to manage all acute pancreatitis patients 2

• Severe cases with persistent organ failure require intensive care setting with complete monitoring and organ support 3
• Management in or referral to a specialized unit is necessary for patients with extensive necrotizing pancreatitis or other complications 2

Expected Outcomes

Overall mortality from acute pancreatitis should be less than 10%, and less than 30% in severe disease 3, 2

• The correct diagnosis should be established within 48 hours in all cases 2
• Etiology should be determined in at least 80% of cases, with no more than 20% classified as idiopathic 2

Common Pitfalls to Avoid

• Do not delay fluid resuscitation while waiting for diagnostic confirmation—treat aggressively until severity is established 5
• Do not routinely use prophylactic antibiotics as this may promote resistant organisms without clear mortality benefit 3
• Do not keep patients NPO unnecessarily—early enteral feeding in severe cases improves outcomes 3, 2
• Do not discharge patients with biliary pancreatitis without definitive gallstone management as this leads to recurrence 3, 2
• Do not rely on CT imaging for initial diagnosis—it is reserved for complications or deterioration 3, 2