Pancreatitis
Key points
Aetiology in children
Idiopathic
Genetic
Trauma
Congenital abnormalities e.g. pancreas divisum, choledochal cyst
Gallstones - haemolytic anaemias
Cystic fibrosis
Infective: In order of most common organisims - Hepatitis B, Cocksackie B, Echovirus, Mumps (paramyxovirus)
Drugs e.g. L Asparaginase in leukaemia
Embryology of the pancreas
Dorsal and ventral pancreatic buds develop from the foregut and rotate then fuse
Pancreatobiliary maljunction can happen when there is problems with fusion
Genetics
PRSS1 (cationic trypsinogen) gene - most common - autosomal dominant
CTRC (chymotrypsin) and CASR (calcium-sensing receptor)
SPINK1 - high risk of chronic pancreatitis
IGG4
Schwachman-Diamond syndrome
Autosomal recessive
1. Pancytopenia
2. Pancreatic insufficiency
3. Growth restriction
Investigations
Amylase/Lipase to confirm diagnosis
Liver function tests, calcium etc for Glasgow score
Faecal elastase for chronic pancreatitis (will be low)
USS for gallstones
CT from 7 days onwards if complications suspected such as necrosis, splenic vessel pseudoaneurysm
Peripancreatic collections can form pseudocyst after developing thick wall (usually takes 3-4 weeks)
CT/MRCP to diagnose and to plan drainage
Secretin given before MRCP can make it more sensitive in detecting pancreas divisum - by increasing sphincter of Oddi pressure
Management
Do not use prophylactic antibiotics - selects out resistant organisms in later collections
Always attempt enteral feeds - NJ tube may be needed
Endoscopic cystgastrostomy e.g. AXIOS hot stent for drainage of pseudocyst that is not resolving
Remove stent endoscopically in 4-6 weeks, can perform cholecystectomy at the same time if GS present
Necrosectomy for extremely rare cases of infected necrosis not responding to supportive measures
10-20% mortality
Cases of chronic pancreatitis with intractable pain and a dilated pancreatic duct may be suitable for a pancreatojejunostomy
References
Suzuki M, Sai JK, Shimizu T. Acute pancreatitis in children and adolescents. World J Gastrointest Pathophysiol. 2014 Nov 15;5(4):416-26. doi: 10.4291/wjgp.v5.i4.416. PMID: 25400985; PMCID: PMC4231506.
Panchoo AV, VanNess GH, Rivera-Rivera E, Laborda TJ. Hereditary pancreatitis: An updated review in pediatrics. World J Clin Pediatr. 2022 Jan 9;11(1):27-37. doi: 10.5409/wjcp.v11.i1.27. PMID: 35096544; PMCID: PMC8771313.
Farooqui SM, Ward R, Aziz M. Shwachman-Diamond Syndrome. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507866/
Boam T et al. Surgical drainage procedures for paediatric chronic pancreatitis: a scoping review. Pediatr Surg Int. 2022 Dec;38(12):1949-1964. doi: 10.1007/s00383-022-05242-8. Epub 2022 Sep 26. PMID: 36163306.