How should acute pancreatitis in pediatric patients be assessed and managed?

Acute Pancreatitis in Pediatric Patients

Diagnose pediatric acute pancreatitis when at least 2 of 3 criteria are met: abdominal pain compatible with pancreatitis, serum amylase and/or lipase ≥3 times upper limit of normal, and imaging findings consistent with acute pancreatitis. 1

Diagnosis

Clinical and Laboratory Criteria

• Lipase is preferred over amylase for diagnosis, as elevations >3 times upper limit of normal (in absence of renal failure) are most specific for acute pancreatitis 2
• Elevations <3 times upper limit have low specificity and are consistent with but not diagnostic of pancreatitis 2
• Abdominal pain with vomiting are the cardinal presenting symptoms in children 3, 1

Imaging Approach

• Obtain abdominal ultrasound at admission to detect gallstones, biliary sludge, or choledocholithiasis—biliary disease causes 29% of pediatric cases 4
• Repeat ultrasound if initially negative, as stones can be missed 2, 5
• Contrast-enhanced CT should be reserved for diagnostic uncertainty or clinical deterioration, not routine use 6
• Critical timing: perform CT at 72-96 hours after symptom onset to accurately assess pancreatic necrosis; earlier imaging underestimates necrosis extent 2, 6

Etiology Determination

Common Pediatric Causes

• Biliary disease (29%), drugs/toxins, infections, trauma, and anatomic abnormalities are the primary etiologies in children—distinctly different from adult patterns 3, 7, 4
• Choledochal cysts account for a significant proportion of biliary pancreatitis in pediatric patients 4
• Establish etiology in at least 75-80% of cases; >20% classified as idiopathic suggests inadequate workup 5

Initial Workup

• Measure serum amylase/lipase, triglycerides, calcium, and liver chemistries (bilirubin, AST, ALT, alkaline phosphatase) at admission 2
• Early elevation of aminotransferases or bilirubin strongly suggests gallstone etiology 5, 8
• Document medication history thoroughly to identify drug-induced pancreatitis 5
• If ultrasound negative and etiology unclear, use MRCP or endoscopic ultrasound to screen for occult choledocholithiasis 2

Severity Assessment

Risk Stratification Within 48 Hours

• Classify as mild (80% of cases) versus severe (20% of cases) based on presence of persistent organ failure 6, 7
• Severe disease is defined by persistent organ failure (>48 hours) and/or infected pancreatic necrosis 2
• Patients with persistent organ failure require ICU admission with full hemodynamic monitoring 2, 6
• Monitor closely within first 48 hours for development of cardiovascular, respiratory, or renal failure 1

Prognostic Tools

• APACHE II score >8 predicts severe disease in adults; pediatric-specific scoring systems are less validated 2
• C-reactive protein >150 mg/L at 48 hours indicates severe disease 2

Management

Fluid Resuscitation (First 24-72 Hours)

• Initiate aggressive fluid resuscitation with Lactated Ringer's solution: 20 ml/kg bolus followed by 3 ml/kg/hour continuous infusion 6
• Reassess hemodynamic status every 12 hours by monitoring hematocrit, BUN, creatinine, and lactate 6
• Avoid fluid overload, which worsens respiratory status and outcomes 6, 8

Nutritional Support

• Begin enteral nutrition within 24 hours rather than keeping NPO—this prevents gut failure and infectious complications 6, 1
• Nasogastric feeding is effective in approximately 80% of pediatric patients 2, 6
• Use oral, gastric, or jejunal route as tolerated; enteral nutrition preferred over total parenteral nutrition 2, 1
• If nutritional support needed beyond 7 days and enteral route fails, use total parenteral nutrition 2

Pain Management

• Hydromorphone is the preferred opioid for analgesia in non-intubated patients 6
• Use opioid medications when opioid-sparing measures are inadequate 1
• Avoid NSAIDs when any evidence of acute kidney injury or renal impairment exists 6, 8

Antibiotic Use

• Do NOT administer prophylactic antibiotics, even in predicted severe or necrotizing pancreatitis 6, 1
• Antibiotics indicated only for documented infections (respiratory, urinary, biliary, catheter-related) 6
• When antibiotics required for confirmed infection, intravenous cefuroxime offers reasonable efficacy 6
• Maximum duration of 14 days if prophylaxis used (though not recommended) 2

Management of Biliary Pancreatitis

ERCP Indications

• Urgent ERCP within 24 hours for patients with concomitant cholangitis 2, 8
• Early ERCP within 72 hours for high suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated CBD, jaundice) 2, 8
• Endoscopic papillotomy may prevent recurrent attacks in children with biliary sludge or gallstones 4

Cholecystectomy Timing

• For mild gallstone pancreatitis: perform cholecystectomy during same hospital admission, ideally within 2 weeks and no later than 4 weeks after discharge 2, 8
• For severe pancreatitis: delay cholecystectomy until complete resolution of complications 8
• All seven children with choledochal cysts in one series required hepaticojejunostomy 4

Complications Management

Monitoring for Complications

• Suspect infected necrosis if fever, worsening symptoms, or sepsis persist beyond 7-10 days 6
• Perform CT in patients with persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission 2, 6
• Procalcitonin is the most sensitive laboratory marker for detecting pancreatic infection 6

Infected Necrosis Approach

• Confirm infection by CT-guided fine-needle aspiration with Gram stain and culture 6
• Delay definitive surgical intervention beyond 4 weeks when feasible—early surgery (<4 weeks) markedly increases mortality 6
• Adopt step-up approach: begin with percutaneous or endoscopic drainage before considering surgery 6

Common Pitfalls to Avoid

• Do not obtain CT before 72 hours—early scans miss full extent of pancreatic necrosis 6
• Do not keep patients NPO—early enteral feeding within 24 hours improves outcomes 6, 1
• Do not use prophylactic antibiotics—no benefit demonstrated and may promote resistance 6, 1
• Do not miss biliary disease—jaundice and abnormal liver function tests are key clues in children 4
• Do not classify >20% as idiopathic—this indicates inadequate etiologic workup 5
• Do not use NSAIDs for pain control if any renal impairment present 6, 8

Expected Outcomes

• Overall mortality should be <10%; mortality for severe pancreatitis is <30% 6
• Most children have mild disease with spontaneous resolution, but up to one-third develop moderate/severe disease or progress to recurrent/chronic pancreatitis 7
• Persistent organ failure >48 hours carries highest mortality risk 6
• Systemic and local complications occur in up to one-third of pediatric patients 7