IAP Guideline for Acute Pancreatitis in Children
The diagnosis of pediatric acute pancreatitis requires at least 2 of 3 criteria: abdominal pain compatible with AP, serum amylase and/or lipase ≥3 times upper limits of normal, and imaging findings consistent with AP, with management focusing on adequate fluid resuscitation within 24 hours, early enteral nutrition as tolerated, and appropriate analgesia. 1
Diagnostic Criteria
Clinical and Biochemical Requirements
Diagnosis requires meeting at least 2 of the following 3 criteria: 2, 1
Serum lipase is preferred over amylase as the diagnostic marker due to higher specificity for pancreatic tissue, longer elevation duration, and better sensitivity 4, 2
The diagnostic threshold of >3 times the upper limit of normal has the highest specificity for acute pancreatitis 3
Initial Laboratory Workup
- All patients should have serum obtained at admission for: 2
- Amylase or lipase level
- Liver chemistries (bilirubin, AST, ALT, alkaline phosphatase)
- Triglyceride level
- Serum calcium level
Imaging Strategy
Initial Imaging
- Abdominal ultrasonography should be performed at admission primarily to identify gallstones or choledocholithiasis as the etiology, not for diagnosis of pancreatitis itself 4, 2, 3
- The pancreas is poorly visualized in 25-50% of cases on ultrasound due to overlying bowel gas 4, 3
Advanced Imaging Indications
Contrast-enhanced CT should be reserved for: 4, 2
- Uncertain diagnosis
- Predicted severe disease (APACHE II score >8)
- Evidence of organ failure during initial 72 hours
- Clinical deterioration
Optimal timing for contrast-enhanced CT is 72-96 hours after symptom onset to accurately assess pancreatic necrosis, as early CT underestimates necrotic areas 5, 4
Severity Assessment
Timing and Tools
- Severity stratification should be completed within 48 hours of admission using established scoring systems 2
- APACHE II score with cutoff of ≥8 predicts severe disease 5, 4
- Persistent organ failure (>48 hours) is the most reliable marker of severe disease and mortality risk 2, 3
Clinical Monitoring
- Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours 1
- Corrected serum calcium <2 mmol/L is a well-established negative prognostic factor requiring ICU admission 2
Management Principles
Fluid Resuscitation
- Adequate fluid resuscitation with crystalloid is key, especially within the first 24 hours 1
- General supportive care must include vigorous fluid resuscitation, supplemental oxygen as required, and correction of electrolyte and metabolic abnormalities 5
Nutritional Support
- Enteral nutrition should be started as early as tolerated (generally within 24 hours), whether through oral, gastric, or jejunal route 5, 1
- Early oral feeding (within 24 hours) reduces the risk of interventions for necrosis by 2.5-fold compared to delayed feeding 5
- In patients unable to feed orally, enteral nutrition is strongly preferred over parenteral nutrition to protect gut mucosal barrier and reduce bacterial translocation 5
- Nasojejunal tube feeding using elemental or semi-elemental formula is preferred over total parenteral nutrition in patients likely to remain NPO for more than 7 days 5, 2
Pain Management
- Analgesia may include opioid medications when opioid-sparing measures are inadequate 1
- Pain control must be provided to all patients as part of general supportive care 5
Etiology Determination
Common Pediatric Causes
- The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin exposure, and idiopathic causes 6
- Other pediatric-specific etiologies include infections, trauma, and anatomic abnormalities 7
Diagnostic Workup for Etiology
The etiology should be established in at least three-fourths of patients 2
Further evaluation may include: 2
- Magnetic resonance cholangiopancreatography (MRCP)
- Sweat chloride testing
- Genetic testing
- Endoscopic ultrasound (EUS)
For unexplained pancreatitis in patients over 40 years, CT or EUS should be performed to rule out underlying pancreatic malignancy 4, 2
Role of ERCP
Indications for Urgent ERCP
- Urgent ERCP (within 24 hours) is required for patients with gallstone pancreatitis who have concomitant cholangitis 5, 2
- Early ERCP (within 72 hours) should be performed with high suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated common bile duct, jaundice) 5, 2
Limited Role in Routine Cases
- Routine urgent ERCP is NOT recommended in patients with acute biliary pancreatitis without cholangitis 5
- ERCP has limited roles in diagnosis and management of pediatric acute pancreatitis 1
Interventions NOT Recommended
Prophylactic Measures
Little evidence supports the use of: 1
- Prophylactic antibiotics
- Antioxidants
- Probiotics
- Protease inhibitors
There is no role for prophylactic antibiotics in patients with any severity of acute pancreatitis 5
Follow-up Considerations
Monitoring for Complications
- Children should be carefully followed for development of early or late complications and recurrent attacks of acute pancreatitis 1
- Systemic and local complications, including SIRS, necrosis, and fluid collections, can occur in up to one-third of patients 6
- Up to one-third of pediatric patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis 6
Key Clinical Pitfalls
Diagnostic Errors to Avoid
- Never rely on clinical assessment alone, as it misclassifies approximately 50% of patients and frequently mimics other acute abdominal conditions 4, 3
- Do not use plain abdominal x-rays for diagnosis, as findings are unreliable and non-specific 3
- Avoid routine CT scans in uncomplicated cases, as early CT may underestimate pancreatic necrosis and rarely changes initial management 5, 4