From the Guidelines
Pediatric pancreatitis should be managed with supportive care, including IV fluids, pain control, and bowel rest, with a focus on early nutrition reintroduction, preferably through enteral feeding, as this approach reduces complications and improves outcomes, as suggested by the most recent guidelines 1.
Key Considerations
- The management of pediatric pancreatitis requires a multidisciplinary approach, considering the patient's hemodynamic status, and the potential need for imaging studies such as CT scans or MRCP to assess the severity of the condition and guide treatment decisions 1.
- The choice of diagnostic technique should be based on the patient's hemodynamic status, with E-FAST being a rapid and effective method for detecting free fluid and solid organ injury in unstable patients 1.
- Repeated and combined measurement of serum amylase and lipase levels can support clinical evaluation in suspicion of pancreatic injury, with elevated and/or increasing levels indicating the need for further investigation 1.
- Serial clinical examination is an essential part of follow-up after pancreatic trauma, and CT scans with intravenous contrast are crucial in diagnosing duodeno-pancreatic injuries in hemodynamically stable patients 1.
Treatment Approach
- Supportive care is the cornerstone of treatment, with IV fluids, pain control, and bowel rest being essential components, as well as early nutrition reintroduction to reduce complications and improve outcomes 1.
- In cases of severe pancreatitis, management should focus on addressing organ failure, infection, and local complications, with a multidisciplinary approach involving surgeons, gastroenterologists, and critical care specialists 1.
- Endoscopic retrograde cholangiopancreatography (ERCP) can be used for both diagnosis and treatment in suspected pancreatic duct and extrahepatic biliary tree injuries in hemodynamically stable patients 1.
Long-term Management
- Children with recurrent episodes of pancreatitis should be evaluated for genetic causes, such as PRSS1, SPINK1, or CFTR mutations, and long-term management should focus on avoiding triggers, maintaining a low-fat diet, and addressing any underlying causes when possible 1.
- Pancreatic enzyme replacement may be necessary in cases of exocrine insufficiency, and patients should be monitored for potential complications, such as pseudocysts, necrosis, and progression to chronic pancreatitis 1.
From the Research
Definition and Diagnosis of Pediatric Pancreatitis
- The diagnosis of pediatric acute pancreatitis should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions, which includes meeting at least 2 out of 3 criteria: abdominal pain compatible with AP, serum amylase and/or lipase values ≥3 times upper limits of normal, and imaging findings consistent with AP 2.
- Pediatric acute pancreatitis is an infrequent but potentially serious condition in children, with most having mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis 3.
Management of Pediatric Pancreatitis
- Supportive care with fluids, pain medications, and nutrition remain the mainstay for acute pancreatitis management 4.
- Adequate fluid resuscitation with crystalloid appears key, especially within the first 24 hours 2.
- Analgesia may include opioid medications when opioid-sparing measures are inadequate 2.
- Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route 2.
- The use of lactated Ringer's solution compared with normal saline is associated with a shorter length of stay in pediatric acute pancreatitis 5.
- Aggressive hydration with lactated Ringer's solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography 6.
Complications and Outcomes
- Systemic and local complications, including SIRS, necrosis, and fluid collections, can occur in up to one-third of patients, and care is largely supportive with a careful step-up approach to fluid collections and necrosis 3.
- Children should be carefully followed for development of early or late complications and recurrent attacks of AP 2.
- The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin, and idiopathic 3.