Definitions of pediatric pancreatitis and survey of present clinical practices

Effects of Second-Hand Smoke on Pancreatitis in Children

OBJECTIVES

Pediatric pancreatitis incidence is increasing, but little is known about risk factors. Smoking increases the risk for adult pancreatitis and has been shown to affect CFTR function in vitro. Therefore, we evaluated passive smoke exposure effects on disease outcomes in children with various pancreatitis etiologies.

METHODS

We conducted a 5-year retrospective chart review of patients admitted for pancreatitis to Children's Healthcare of Atlanta. Demographic data, etiology of pancreatitis, and number of hospitalizations with length of stay (LOS) were compared with smoking exposure, obtained through telephone query.

RESULTS

Of the 134 subjects admitted for pancreatitis, 90 reported no smoke exposure (none), 33 reported outdoor smoke exposure (outside), and 11 reported exposure to indoor smoking (inside). Average hospital admissions (P = 0.038) and LOS (P = 0.004) were significantly higher among subjects with inside smoke exposure compared with those with outdoor or no exposure. Average hospital admissions were significantly higher in subjects with CFTR mutations compared with those with nongenetic or other genetic etiologies (P ≤ 0.001).

CONCLUSIONS

Second-hand smoke exposure may increase hospital admission rates and LOS for pediatric pancreatitis. Children with an identifiable CFTR mutation may have increased risk for hospital admissions compared with those who do not.

Thrombopoietin Contributes to Extreme Thrombocytosis After Pediatric Pancreatectomy With Islet Autotransplantation

OBJECTIVE

This study aims to explore the role of thrombopoietin (TPO) production in extreme thrombocytosis that is often observed after pancreatectomy with islet autotransplantation (IAT) and the effectiveness of hydroxyurea in thrombocytosis management.

METHODS

Retrospective chart review was performed for all patients who underwent pancreatectomy with IAT at our institution between April 1, 2015, and December 31, 2016. Data evaluated included demographics, platelet counts, TPO levels, and thrombocytosis management strategies.

RESULTS

Twelve total and 1 subtotal pancreatectomy with IAT cases were reviewed. All operations included splenectomy. No major surgical or thrombotic complications occurred. Thrombopoietin levels, normal preoperatively, rose significantly (median, 219 pg/mL) soon after surgery, peaking on median postoperative day 3. Platelet counts, also normal preoperatively, increased within a week of surgery, with 92% over 1000 K/μL (median peak platelet count, 1403 K/μL). Platelet counts and TPO levels dropped after hydroxyurea initiation in most patients.

CONCLUSIONS

After pancreatectomy with IAT, patients experienced marked TPO rise and subsequent thrombocytosis, and both decreased significantly after hydroxyurea initiation. These data suggest that TPO elevation and associated increased platelet production may be one driver of early extreme post-total pancreatectomy with islet autotransplantation thrombocytosis, and this process may be modulated by hydroxyurea.

Young Age Predicts Acute Pancreatitis Severity in Children

OBJECTIVES

The course and evolution of pediatric acute pancreatitis (AP) is poorly understood. Prognostication models in children perform poorly and lack consensus. We aimed to identify predictors of AP severity, and the risk for AP recurrence.

METHODS

We retrospectively studied all patients hospitalized with AP at a single tertiary center, between January 1995 and June 2016. Patient demographics and admission laboratory data were assessed for severity and recurrence prediction.

RESULTS

A total of 68 patients accounting for a total of 117 (15 moderate-severe) AP episodes were reviewed. Patients with moderate-severe disease were significantly younger (median [interquartile range (IQR)] of 8.3 [4.0-14.4] vs 13.8 [8.1-16.0] years, P = 0.02). Young age at presentation was associated with odds ratio of 3.8 (confidence interval [CI] 1.2-12.1) for children younger than 12 years and 5.8 (CI 1.6-21.4) for children younger than 6 years for developing moderate-severe disease.Further subanalysis of the 59 patients with first-time AP episodes, demonstrated younger age (median [IQR] of 5.3 [2.9-10.4] vs 12.0 [6.3-15.8] years, P = 0.03) and elevated white blood cell count (median [IQR] of 22.8 [11.8-31.3] vs 11.0 [8.1-14.6] 10/L, P < 0.01) of patients with moderate-severe disease, conferring a risk for moderate-severe disease with odds ratio of 7.5 (CI 1.5-38.2) for children younger than 6 years and 5.3 (CI 1.1-25.4) for patients with white blood cell count >15 × 10/L, respectively. Fourteen (23.7%) of 59 patients with first-time episodes had recurrent AP. Analysis of the data at the primary episode failed to identify predictors to indicate future recurrence.

CONCLUSIONS

In our cohort, only young age (<12 years) predicted AP severity. No parameters were identified to predict future development of AP recurrence.

Cystic fibrosis screen positive inconclusive diagnosis (CFSPID): Experience in Tuscany, Italy

OBJECTIVE

The implementation of cystic fibrosis (CF) newborn screening (NBS) has led to identification of infants with a positive NBS test but inconclusive diagnosis classified as "CF screen positive, inconclusive diagnosis" (CFSPID). We retrospectively evaluated the prevalence and clinical outcome of CFSPID infants diagnosed by 2 NBS algorithms in the period from 2011 to 2016 in the Tuscany region of Italy.

METHODS

In 2011-2016, we assessed the diagnostic impact of DNA analysis on the NBS 4-tier algorithm [immunoreactive trypsin (IRT) - meconium lactase - IRT2 - sweat chloride (SC)]. All CFSPID patients repeated SC testing every 6 months, and CFTR gene analysis was performed (detection rate 98%). We reclassified children as: CF diagnosis in presence of at least 2 pathological SC results; healthy carrier or healthy in presence of at least 2 normal SC results for age and either 1 or 0 CF-causing mutations, respectively.

RESULTS

We identified 32 CF and 50 CFSPID cases: 20/50 (40%) were diagnosed only by the IRT-DNA-SC algorithm and 16/50 (32%) only by IRT-meconium lactase-IRT2-SC. Both protocols identified the remaining 14 cases (28%). Thirty-seven of 50 (74%) CFSPID patients had a conclusive diagnosis on December 31, 2017:5 (10%) CF, 17 (34%) healthy and 15 (30%) healthy carriers; 13/50 (26%) cases were asymptomatic with persistent intermediate SC and followed as CFSPID (CF:CFSPID ratio 2.85:1).

CONCLUSIONS

In 6 years, the CF:CFSPID ratio modified from 0.64:1 to 2.85:1, and 10% of CFSPID cases progressed to CF. Genetic analysis improved positive predictive value and identified a higher number of CFSPID infants progressing to CF.

Chronic Pancreatitis: Pediatric and Adult Cohorts Show Similarities in Disease Progress Despite Different Risk Factors

OBJECTIVES

The aim of the present study was to investigate the natural history of chronic pancreatitis (CP); patients in the North American Pancreatitis Study2 (NAPS2, adults) and INternational Study group of Pediatric Pancreatitis: In search for a cuRE (INSPPIRE, pediatric) were compared.

METHODS

Demographics, risk factors, disease duration, management and outcomes of 224 children and 1063 adults were compared using appropriate statistical tests for categorical and continuous variables.

RESULTS

Alcohol was a risk in 53% of adults and 1% of children (P < 0.0001); tobacco in 50% of adults and 7% of children (P < 0.0001). Obstructive factors were more common in children (29% vs 19% in adults, P = 0.001). Genetic risk factors were found more often in children. Exocrine pancreatic insufficiency was similar (children 26% vs adult 33%, P = 0.107). Diabetes was more common in adults than children (36% vs 4% respectively, P < 0.0001). Median emergency room visits, hospitalizations, and missed days of work/school were similar across the cohorts. As a secondary analysis, NAPS2 subjects with childhood onset (NAPS2-CO) were compared with INSPPIRE subjects. These 2 cohorts were more similar than the total INSPPIRE and NAPS2 cohorts, including for genetic risk factors. The only risk factor significantly more common in the NAPS2-CO cohort compared with the INSPPIRE cohort was alcohol (9% NAPS2-CO vs 1% INSPPIRE cohorts, P = 0.011).

CONCLUSIONS

Despite disparity in age of onset, children and adults with CP exhibit similarity in demographics, CP treatment, and pain. Differences between groups in radiographic findings and diabetes prevalence may be related to differences in risk factors associated with disease and length of time of CP.

In-hospital and 90-day outcomes after total pancreatectomy with islet autotransplantation for pediatric chronic and acute recurrent pancreatitis

Total pancreatectomy with islet autotransplantation (TPIAT) is used to treat debilitating chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) that has failed medical and endoscopic therapy. We performed a retrospective review of TPIAT patients at a free-standing children's hospital to evaluate perioperative outcomes. Twenty patients (median age 13, 65% female) underwent TPIAT (2015 through 2017). Of the 20 patients, 95% had CP and 1 patient (5%) had ARP alone. Seventy-five percent of the patients had a pancreatitis-associated genetic mutation; 40% had pancreas divisum. The median surgical time was 757 (IQR 657 to 835) minutes. Median islet equivalents per kg of body weight (IEQ/kg) were 6404 (IQR 5018 to 7554). At 90 days postoperatively vs preoperatively, significantly fewer patients were receiving parenteral nutrition (0% vs 25%, P = .006) and opioids (45% vs 75%, P = .01). Short Form 36-Item Health Survey (SF-36) physical health module scores and total scores improved (34.0 preoperatively vs 54.6 at 90 days, P = .008, and 47.1 vs 65.3, P = .007, respectively); SF-10 physical health scores also improved (13.4 vs 33.1, P = .02). Insulin requirement decreased from 0.5 unit/kg/day to 0.4 unit/kg/day between discharge and 90 days (P = .02). TPIAT is an effective option when debilitating disease persists despite maximal medical and endoscopic therapy. Opioid, parenteral nutrition, and exogenous insulin use can successfully be weaned within 90 days after TPIAT, with gains in health-related quality of life.

INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE Cohort Study: Design and Rationale for INSPPIRE 2 From the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer

We created the INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE (INSPPIRE 2) cohort to study the risk factors, natural history, and outcomes of pediatric acute recurrent pancreatitis and chronic pancreatitis (CP). Patient and physician questionnaires collect information on demographics, clinical history, family and social history, and disease outcomes. Health-related quality of life, depression, and anxiety are measured using validated questionnaires. Information entered on paper questionnaires is transferred into a database managed by Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer's Coordinating and Data Management Center. Biosamples are collected for DNA isolation and analysis of most common pancreatitis-associated genes.Twenty-two sites (18 in the United States, 2 in Canada, and 1 each in Israel and Australia) are participating in the INSPPIRE 2 study. These sites have enrolled 211 subjects into the INSPPIRE 2 database toward our goal to recruit more than 800 patients in 2 years. The INSPPIRE 2 cohort study is an extension of the INSPPIRE cohort study with a larger and more diverse patient population. Our goals have expanded to include evaluating risk factors for CP, its sequelae, and psychosocial factors associated with pediatric acute recurrent pancreatitis and CP.

Accelerating the Drug Delivery Pipeline for Acute and Chronic Pancreatitis: Summary of the Working Group on Drug Development and Trials in Chronic Pancreatitis at the National Institute of Diabetes and Digestive and Kidney Diseases Workshop

The lack of effective therapeutic agents specifically tailored for chronic pancreatitis (CP) has hampered clinical care and negatively impacted patients' lives. New mechanistic insights now point to novel therapies, which involve both recently developed and/or repurposed agents. This working group focused on 2 main outcomes for CP: pain and progression of disease. The goal is to frame the essential aspects of trial design including patient-centered outcomes, proposed methods to measure the outcomes of pain and progression, and study design considerations for future trials to facilitate rapid drug development for patients with CP.

Successful Management of a Child With Drug-induced Necrotizing Pancreatitis During Acute Lymphoblastic Leukemia Therapy: A Case Report

Acute pancreatitis in children acute lymphoblastic leukemia is commonly caused by drugs, for example, L-Asparaginase, pegapargase, steroids. The incidence of this complication is estimated at 6.7% to 18%. Although the majority of drug-induced acute pancreatitis cases are mild, severe cases can rarely occur. This work presents a case of successful management of a child with drug-induced necrotizing pancreatitis during acute lymphoblastic leukemia therapy. This case illustrates that comprehensive care and immediate intensive treatment can rescue patient despite poor prognosis. Administration of octreotide may serve a role in limiting the severity of the disease.

Blood Urea Nitrogen Elevation Is a Marker for Pediatric Severe Acute Pancreatitis

OBJECTIVE

The natural course of patients who develop acute pancreatitis (AP) can range from mild to severe acute pancreatitis (SAP). The aim of this study was to evaluate for early predictors of developing SAP during the first episode of AP in a prospective pediatric cohort.

METHODS

Clinical data were prospectively collected and subsequently analyzed for pediatric patients presenting with their first episode of AP between March 2013 and January 2017 to Cincinnati Children's Hospital Medical Center.

RESULTS

A total of 118 patients were included in the analysis, and 22 (18.6%) developed SAP. Patients who developed SAP had significantly higher values of blood urea nitrogen (BUN) (P = 0.007), magnesium (P = 0.04), glucose (P = 0.03), sodium (P = 0.03), and C-reactive protein (P = 0.02). A logistic regression model with BUN as a predictor of SAP was superior to any other combination of variables (area under the receiver operating characteristic curve, 0.75; 95% confidence interval, 0.61-0.89; sensitivity, 63%; specificity, 81%; positive predictive value, 43%; negative predictive value, 91%).

CONCLUSIONS

This study generated a predictive model using elevated BUN as a significant predictor of SAP. The findings are useful for early identification of pediatric patients at higher risk of developing SAP.

Role of Diagnostic Endoscopic Ultrasound in Idiopathic Acute Pancreatitis and Acute Recurrent Pancreatitis in Children

OBJECTIVES

Endoscopic ultrasound (EUS) is a minimally invasive pancreatic imaging modality. We evaluated children with idiopathic acute pancreatitis (IAP) and acute recurrent pancreatitis (ARP) for changes of chronicity (Rosemont criteria) and biliary risk factors. Diagnostic yield of simultaneously performed transabdominal ultrasonography (TUS) was compared with EUS.

METHODS

This was a prospective observational study. Patients underwent EUS and TUS after 2 months of pancreatitis attack.

RESULTS

Forty-five (18 IAP, 27 ARP) patients underwent EUS and TUS. Mean (standard deviation) age and weight were 9.1 (2.6) years and 32.66 (12.43) kg in IAP, whereas these were 12.2 (3.1) years and 44.84 (15.12) kg in ARP, respectively. Endoscopic ultrasound demonstrated morphological abnormality in 33.3% and 40.7% of IAP and ARP, respectively (P = 0.61), whereas 16.6% and 25.9% were abnormal in TUS. Endoscopic ultrasound showed unequivocal changes of chronicity (11.1% vs 0%) and risk factors only among ARP (25.9% vs 0%; P = 0.03) and demonstrated slightly higher odds ratio (95% confidence interval) as compared with TUS to detect abnormalities in both IAP (2.43 [0.49-14.17], P = 0.28) and ARP (1.94 [0.60-6.47], P = 0.26).

CONCLUSIONS

Applying EUS, changes of chronicity and risk factors were noted only in ARP. Endoscopic ultrasound performed better than TUS in detecting chronicity.

Severe acute pancreatitis in a child with phenylketonuria

We report for the first time severe acute pancreatitis in a child treated for phenylketonuria (PKU) discovered on neonatal screening. This 2-year-old boy was first hospitalized for bilious vomiting and moderate back pain. Laboratory values included a lipase level of 1.142 U/L, a phenylalanine level of 10mg/dL, and computed tomography revealed Balthazar grade E pancreatitis. Continuous enteral feeding was started on the 3rd day after admission. We observed clinical and biological improvement. Etiologic investigations for pancreatitis returned negative. Despite the severity of the pancreatitis, we did not observe decompensation of the metabolic disease. Specific nutritional management was necessary.

Need for recognizing atypical manifestations of childhood sporadic acute viral hepatitis warranting differences in management

Various atypical manifestations have been described in acute viral hepatitis (AVH). We evaluated the prevalence, clinical features, response to treatment and outcome of various atypical manifestations of AVH in children. Consecutive children (≤ 18 years) with AVH due to hepatitis A, B, or E were studied while patients with acute or acute on chronic liver failure were excluded. Diagnosis of atypical manifestations was based on standard criteria. A total of 477 children with AVH (median age 7.0 (5-11) years, 74% boys) were seen; 22% (n = 106) had atypical manifestations. Prolonged cholestasis was the most common (11%), followed by ascites (7%), intravascular hemolysis (3%), relapsing hepatitis (2%), acute pancreatitis (1.3%), and thrombocytopenia (0.7%). Atypical manifestations were more common in HAV as compared to HBV (30% vs. 3%, p = 0.00) and HEV (30% vs. 15%, p = 0.07). Prolonged cholestasis was significantly more common in older children (20% in > 10 years vs. 9% in 6-10 years ; p = 0.009 and 5% in 0-5 years of age [p < 0.000]). Ascites was more common in younger children, although not significant. All patients recovered with supportive treatment.Conclusions: Twenty-two percent of children with AVH have atypical manifestations, more often with HAV infection, and prolonged cholestasis is most common. Recognition of these manifestations ensures correct diagnosis and treatment. What is Known: • Acute viral hepatitis is a major public health problem in developing countries. • There is limited information about atypical manifestations which may lead to unnecessary investigations, delayed diagnosis and morbidity. What is New: • Atypical manifestations are common in children, seen most often with HAV infection, and prolonged cholestasis is most common. • Prompt recognition of these manifestations helps in early diagnosis, appropriate management, and preventing unnecessary investigations. • Ensure follow-up until complete recovery and not to miss underlying chronic liver disease.

Incomplete functional and morphological recovery after acute and acute recurrent pancreatitis in children

BACKGROUND AND AIM

There is lack of data on functional and morphological recovery after an attack of acute pancreatitis (AP) or acute recurrent pancreatitis (ARP) in children. This study aims to evaluate the functional impairment and morphological changes in the pancreas after recovery.

METHODS

All consecutive patients presenting with AP (n = 61) or ARP (n = 35), as per standard diagnostic criteria, were enrolled. After 2 months of pancreatitis, fecal elastase-1 (FE-1) (μg/g) and 2-h oral glucose tolerance test to calculate oral disposition index (DI_o ) (mmol/L) (β-cell function) were performed. Morphological changes were assessed by endoscopic ultrasound and transabdominal ultrasound. Patients with chronic pancreatitis (CP) (n = 27) and healthy children (HC) (n = 26) were included as controls for functional parameters.

RESULTS

At a median follow up of 12 (4-44) and 11 (2-108) months, 66.7% and 75.9% (P = 0.57) of AP and ARP demonstrated exocrine insufficiency (FE-1 < 200), respectively. Mean (SD) FE-1 was 183.64 ± 150.94 (AP), 135.70 ± 103.80 (ARP), 46.56 ± 30.20 (CP), and 240.00 ± 181.83 (HC) (P < 0.001; anova) (AP vs CP, ARP vs CP, and CP vs HC; P < 0.001). Prediabetes due to insulin resistance was seen in 16.6% and 22.6% (P = 0.56) of AP and ARP. Median (interquartile range) DI_o (mmol/L) was comparable between AP (4.20 [2.36, 8.3]) and HC (5.20 [2.89, 8.68]), but was low in ARP (2.97 [1.80, 5.12]), which was comparable with CP (1.91 [1.20, 2.83]). Endoscopic ultrasound demonstrated morphological changes in 25% and 37% (P = 0.34) of AP and ARP, respectively.

CONCLUSION

There was high frequency of biochemical evidence of exocrine insufficiency. β-Cell function (DI_o ) was preserved among AP but was poor in ARP. Nearly one-third showed morphological changes in imaging.

Rapid Progression of Acute Pancreatitis to Acute Recurrent Pancreatitis in Children

OBJECTIVE

Research is lacking on the natural history of acute pancreatitis (AP) progression to acute recurrent pancreatitis (ARP). The aim of this project was to study the progression from AP to ARP among pediatric patients with pancreatitis to better understand the presentation and natural history of pancreatitis.

METHODS

Patients presenting with AP were included in a prospective database in Research Electronic Data Capture. We enrolled 115 patients with AP from March 2013 to November 2016. Physicians completed surveys regarding clinical data for patients with first attack of AP. Patients were followed prospectively, with data on progression entered when patients presented with ARP.

RESULTS

The most common etiologies for the first attack of AP were idiopathic (31%), toxic/drug-related (23%), and biliary/gallstone (18%). Twenty of the 115 patients (17%) developed ARP during the follow-up period. Seventy percent (14/20) of patients with ARP progressed from AP to ARP within 5 months from first diagnosis. A comparison of patients who rapidly progressed to ARP within 3 months (n = 12) to those followed for >3 months without progression in 3 months (n = 97) revealed associations with a higher weight percentile for age (P = 0.045), male sex (P = 0.03), and presence of pancreatic necrosis during first AP attack (P = 0.004). Progression to ARP significantly differed by etiology group with genetics having the highest risk for ARP progression over time and patients with gallstone/biliary, viral/systemic, and obstructive (nongallstone) having the lowest risk for ARP progression over time (P = 0.02).

CONCLUSIONS

Most patients who progressed from AP to ARP progressed within 5 months. The presence of a higher weight percentile for age, male sex, and pancreatic necrosis during the first AP attack are associated with rapid progression to ARP.

Epidemiology of Pediatric Acute Pancreatitis in Taiwan: A Nationwide Population-based Study

OBJECTIVE

Pediatric acute pancreatitis (AP) may be different from adult AP in various respects. This study focuses on the epidemiology and medical resource use of pediatric AP in Taiwan.

METHODS

Patients aged 0 to 18 years with AP were identified from the Taiwan National Health Insurance Research Database based on the International Classification of Diseases, Ninth Revision code of AP 577.0. The medical resource use was measured by length of hospital stay and hospital charges.

RESULTS

Between 2000 and 2013, a total of 2127 inpatient cases of pediatric AP were collected, which represented a hospitalization rate of 2.83 per 100,000 population. The incidence by age had 2 peaks, the first peak was at age 4 to 5 years old, and the second one started rising from 12 to 13 years old until adulthood. The incidence by year increased from 2.33 to 3.07 cases per 100,000 population during the study period. The average hospital stay is steady, but the medical cost is increasing. Girls have longer hospital stays, higher medical expenditures, more use of endoscopic retrograde cholangiopancreatography possibly due to more comorbidities with biliary tract diseases than boys (P < 0.05). The mortality in cases of AP is mostly associated with systemic diseases rather than AP itself.

CONCLUSIONS

The incidence of pediatric AP in Taiwan is in a rising trend. There are gender differences in length of hospital stay, medical costs, use of endoscopic retrograde cholangiopancreatography and comorbidities.

Clinical expression of cystic fibrosis in a large cohort of Italian siblings

Background

A clinical heterogeneity was reported in patients with Cystic Fibrosis (CF) with the same CFTR genotype and between siblings with CF.

Methods

We investigated all clinical aspects in a cohort of 101 pairs of siblings with CF (including 6 triplets) followed since diagnosis.

Results

Severe lung disease had a 22.2% concordance in sib-pairs, occurred early and the FEV₁% at 12 years was predictive of the severity of lung disease in the adulthood. Similarly, CF liver disease occurred early (median: 15 years) and showed a concordance of 27.8% in sib-pairs suggesting a scarce contribution of genetic factors; in fact, only 2/15 patients with liver disease in discordant sib-pairs had a deficiency of alpha-1-antitrypsin (a known modifier gene of CF liver phenotype). CF related diabetes was found in 22 pairs (in 6 in both the siblings). It occurred later (median: 32.5 years) and is strongly associated with liver disease. Colonization by P. aeruginosa and nasal polyposis that required surgery had a concordance > 50% in sib-pairs and were poorly correlated to other clinical parameters. The pancreatic status was highly concordant in pairs of siblings (i.e., 95.1%) but a different pancreatic status was observed in patients with the same CFTR mutations. This suggests a close relationship of the pancreatic status with the “whole” CFTR genotype, including mutations in regulatory regions that may modulate the levels of CFTR expression. Finally, a severe course of CF was evident in a number of patients with pancreatic sufficiency.

Conclusions

Physicians involved in care of patients with CF and in genetic counseling must be aware of the clinical heterogeneity of CF even in sib-pairs that, at the state of the art, is difficult to explain.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0766-6) contains supplementary material, which is available to authorized users.

Pediatric Pancreatitis-Molecular Mechanisms and Management

Pediatric pancreatitis is an emerging field with an increasing incidence of disease. Management of pediatric pancreatitis is understudied and, therefore, extrapolated from adult studies (although the etiologies are different). There is evidence that feeding is safe in mild acute pancreatitis in children without increased pain or length of stay. Studies are needed to predict course of the disease, disease severity, and risk of chronic pancreatitis in children.

Lower 6-MMP/6-TG Ratio May Be a Therapeutic Target in Pediatric Autoimmune Hepatitis

BACKGROUND

Azathioprine (AZA) is the mainstay of maintenance therapy in pediatric autoimmune hepatitis (AIH). The use of thiopurines metabolites to individualize therapy and avoid toxicity has not, however, been clearly defined.

METHODS

Retrospective analysis of children ≤18 years diagnosed with AIH between January 2001 and 2016. Standard definitions were used for treatment response and disease flare. Thiopurine metabolite levels were correlated with the corresponding liver function test.

RESULTS

A total of 56 children (32 girls) were diagnosed with AIH at a median age of 11 years (interquartile range [IQR] 9). No difference in 6-thioguanine-nucleotide (6-TG) levels (271[IQR 251] pmol/8 × 10 red blood cell vs 224 [IQR 147] pmol/8 × 10 red blood cell, P = 0.06) was observed in children in remission when compared with those who were not in remission. No correlation was observed between the 6-TG and alanine aminotransferase levels (r = -0.179, P = 0.109) or between 6-methyl-mercaptopurine (6-MMP) and alanine aminotransferase levels (r = 0.139, P = 0.213). The 6-MMP/6-TG ratio was significantly lower in patients who were in remission (2[7] vs 5 (10), P = 0.04). Using a quartile analysis, we found that having a ratio of <4 was significantly associated with being in remission with OR 2.50 (95% confidence interval 1.02-6.10), P = 0.047. Use of allopurinol with low-dose AZA in 6 children with preferential 6-MMP production brought about remission in 5/6 (83.3%).

CONCLUSIONS

Thiopurine metabolite levels should be measured in patients with AIH who have experienced a loss of remission. A 6-MMP/6-TG ratio of <4 with the addition of allopurinol could be considered in these patients.

Acute pancreatitis after major spine surgery: a case report and literature review

Background

Acute pancreatitis has been described as potential complication of both abdominal and non-abdominal surgeries. The pathogenetic mechanism underlying acute pancreatitis in spine surgery may include intraoperative hemodynamic instability causing prolonged splanchnic hypoperfusion, as well as mechanical compression of the pancreas due to scoliosis correction, with a higher risk in cases of more extended fusions, especially in young adults with lower body mass index (BMI).

Case presentation

We report here a case of postoperative acute pancreatitis with benign evolution in a young female patient after the first and second surgery of a two-stage correction of right thoracic idiopathic scoliosis.

In December 2017, the patient underwent first-stage T4-L3 posterior arthrodesis with T7-T12 osteotomies and temporary magnetic bar. Intraoperative blood loss required massive transfusion. In the immediate postoperative period, the patient started reporting nausea/vomiting, abdominal pain at pressure, moderate meteorism, abdominal distension, hypoactive bowel sounds, and fever. Laboratory tests indicated a progressive increase in aspartate aminotransferase, alanine aminotransferase, serum amylase, lipase, phospho-creatine kinase, and reactive C-protein. A CT scan showed free abundant abdominal fluid in the hepatic, renal, pancreatic, and pelvic regions. After the diagnosis, a hypolipidic diet was initiated, and good hydration per os was maintained. After gastroenterologic consultation, somatostatin, rifaximin, and ursodehoxycholic acid were initiated and maintained for 8 days. In the following days, laboratory tests showed a slow but consistent decrease in liver and pancreatic enzymes until normalization. In January 2018, the patient underwent second-stage surgery with removal of magnetic bar, definitive posterior fusion, and instrumentation T4-L3. Laboratory tests showed a second, even more significant, increase in the amylase and lipase level and a moderate increase in the reactive C-protein. Therapy was maintained until complete normalization of amylase and lipase levels.

Conclusions

Early recognition of symptoms plays a key role in preventing severe morbidity after scoliosis surgery. When symptoms suggest abdominal complication, pancreatic and liver enzymes are to be evaluated for posing prompt diagnosis. Gastroenterologic consultation and eventual imaging are further steps in differential diagnosis and treatment of this rare complication.

Electronic supplementary material

The online version of this article (10.1186/s13013-018-0170-2) contains supplementary material, which is available to authorized users.

Concordance of the Balthazar Grade and the Revised Atlanta Classification: Proposing a Modified Balthazar Grade to Predict the Severity of Acute Pancreatitis in Pediatric Population

OBJECTIVES

The aim of this study was to compare the concordance of the Balthazar grade and the revised Atlanta classification and then establish a modified radiological scoring system that would predict 3 degrees of severity of acute pancreatitis (AP) based on the latest Atlanta classification.

METHODS

A retrospective study enrolling pediatric inpatients with AP who had completed computed tomography was conducted between January 2006 and March 2018. The concordance of the 2 radiological scoring systems was assessed with κ statistic.

RESULTS

The Balthazar grade was unable to accurately predict the severity of AP compared with the revised Atlanta classification. However, a modified Balthazar grading system defining patents with Balthazar grades A to C as mild, grade D as moderately, and grade E as severe presented perfect agreement with the revised Atlanta classification across the enrolled population (κ, 0.85; 95% confidence interval, 0.73-0.97). The concordance of the modified Balthazar score and the revised Atlanta classification remained a perfect degree of agreement across repeated tests in 90 random samples (κ, 0.85; 95% confidence interval, 0.85-0.85).

CONCLUSIONS

The modified Balthazar grade demonstrated perfect agreement with the latest Atlanta classification for AP severity scoring. As such, the modified Balthazar grade can be used to predict 3 degrees of severity of AP.

Prevalence of abnormal glucose metabolism in pediatric acute, acute recurrent and chronic pancreatitis

Type 3C Diabetes, or diseases of the exocrine pancreas has been reported to occur in approximately 30% of adult patient with pancreatitis. The incidence of glucose abnormalities or risk factors that may predict the development of abnormal glucose in the pediatric pancreatitis population is not known. We performed a retrospective chart review from 1998–2016 for patients who carry the diagnosis of acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP). We extracted glucose values, HbA1c%, and data from oral glucose tolerance and mixed meal testing with timing in relation to pancreatic exacerbations. Patient characteristic data such as age, gender, body proportions, family history of pancreatitis, exocrine function and genetic mutations were also assessed. Abnormal glucose was based on definitions put forth by the American Diabetes Society for pre-diabetes and diabetes. Fifty-two patients had AP and met criteria. Of those, 15 (29%) had glucose testing on or after the first attack, 21 (40%) were tested on or after the second attack (in ARP patients) and 16 (31%) were tested after a diagnosis of CP. Of the patients tested for glucose abnormalities, 25% (13/52) had abnormal glucose testing (testing indicating pre-DM or DM as defined by ADA guidelines. A significantly higher proportion of the abnormal glucose testing was seen in patients (85%, 11/13) with a BMI at or greater than the 85^th percentile compared to the normal glucose patients (28%, 11/39) (p = 0.0007). A significantly higher proportion of the abnormal glucose patients (77%, 10/13) had SAP during the prior AP episode to testing compared to the 10% (4/39) of the normal glucose patients (p<0.0001). Older age at DM testing was associated with a higher prevalence of abnormal glucose testing (p = 0.04). In our patient population, a higher proportion of glucose abnormalities were after the second episode of pancreatitis, however 62% (8/13) with abnormalities was their first time tested. We identified obesity and having severe acute pancreatitis (SAP) during the prior AP episode to testing could be associated with abnormal glucose. We propose that systematic screening for abnormal glucose after the first episode of acute pancreatitis in order to better establish the timing of diabetes progression.

Percentile reference curves for normal pancreatic dimensions in Indian children

Objectives:

This study aims at determining the normal pancreatic dimensions in pediatric age groups considering demographic parameters and thus developing percentile reference curves for normal pancreatic dimensions in Indian children.

Setting and Design:

It is a cross-sectional study.

Materials and Methods:

A hospital-based cross-sectional study was planned at a children hospital during July 2016–December 2017, in which the pancreatic dimensions of 1078 normal children in the age range of 1 month to 19 years were obtained through abdominal ultrasonography (USG). The demographic details like age and gender were obtained for each child.

Statistical Analysis Used:

Percentile reference curves were obtained with reference to age for each gender type independently. Generalized additive models for location, scale, and shape were used to obtain percentile plots for each pancreatic part.

Results:

The mean age of children was 6.65 ± 4.43 years and the male-to-female ratio was 1.63:1. The head, body, and tail dimensions increased with the age. For head, up to 25^th percentile, the curves were similar for both genders, while subsequent curves were higher in males as compared to females. Similar was the observation for body of pancreas. For tail, up to 75^th percentile, the curves were similar for both genders.

Conclusion:

The normal ranges can be supportive in diagnosis of illness related to pancreas. The dimensions within 5–95^th percentile along with iso-echogenicity can be regarded as normal, while the dimensions beyond these limits along with change of echogenicity can be suspected for pancreatic disorders.

Pancreatic Insufficiency: What Is the Gold Standard?

Endoscopic pancreatic function testing assesses exocrine insufficiency and chronic pancreatitis. Indirect pancreatic function tests have limited sensitivity and specificity in early disease stages. Magnetic resonance cholangiopancreatography shows promise in detecting early changes as a direct measure of pancreatic function. This article summarizes the evolution of pancreatic function testing and highlights areas for future research, such as development of diagnostic biomarkers to stratify disease severity and targeted therapies to retard disease progression.

Normal pancreatic parenchymal thickness by CT in healthy children

BACKGROUND

Chronic pancreatitis is increasingly recognized in the pediatric population. Atrophy is an important, but qualitative, finding of chronic pancreatitis. To transition to a quantitative measure that can specifically define atrophy requires knowledge of normal pancreatic parenchymal bulk in children.

OBJECTIVE

The purpose of this study was to define normal pancreatic thickness (linear measurements) at multiple anatomic locations in the pancreas of healthy children.

MATERIALS AND METHODS

This was an Institutional Review Board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study. Three reviewers measured the thickness of the pancreas at four locations (head, neck, body, tail) on computed tomography (CT) examinations performed with intravenous contrast in children without a history of pancreatic disease. Measurements were made on 140 examinations, evenly distributed among 7 age groups (3-16.99 years) with 10 males and 10 females in each group. Agreement and bias between reviewers were assessed by intra-class correlation coefficients (ICC) and Bland-Altman analyses. Correlation with age, height and weight were assessed with Spearman's rho (ρ).

RESULTS

The mean (for 3 readers) thicknesses of the head, neck, body and tail were 1.3-2 cm, 0.7-1 cm, 0.9-1.6 cm and 1-1.6 cm, respectively, depending on patient age. Measurement agreement between reviewers was fair to good (ICC: 0.52-0.7). Bias between reviewers ranged from 0 to 3 mm. Pancreatic thickness was weakly to moderately correlated with age (ρ=0.39-0.52), height (ρ=0.44-0.61) and weight (ρ=0.51-0.64).

CONCLUSION

We have defined normal ranges for thickness of the pancreas at four locations, and have shown that these measurements depend on patient age and size. These data may be useful to more objectively define pancreatic atrophy in children with suspected pancreatic disease.

Genetic predisposition in pancreatitis

PURPOSE OF REVIEW

Genetic mutations are the primary cause for acute recurrent (ARP) and chronic pancreatitis in children. Further, our medical approach for many diseases is changing from a one-drug therapy to more individualized therapeutic strategies. In respect to the therapeutic management of ARP/chronic pancreatitis, this entails an understanding of the individual, mainly genetic, risk factors that led to pancreatitis disease.

RECENT FINDINGS

New pancreatitis-associated genes are continuously emerging from increasingly large genetic cohort studies. Furthermore, newer research findings demonstrate that multiple genetic and nongenetic factors are required to increase the individual risk for developing ARP/chronic pancreatitis. Last, there is new exciting development towards targeted pancreatitis therapy in the future.

SUMMARY

This review introduces the current concept of ARP/chronic pancreatitis as a complex disease caused by multiple genetic and nongenetic factors. This warrants careful evaluation of these patients and ideally consultation of a pancreas expert to help understand individual genetic risk profiles and to provide more effective patient consultation.

Impact of Obesity on Pediatric Acute Recurrent and Chronic Pancreatitis

OBJECTIVE

The aim of this study was to assess the impact of obesity on pediatric acute recurrent pancreatitis or chronic pancreatitis (CP).

METHODS

We determined body mass index (BMI) status at enrollment in INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) cohort using CDC criteria for pediatric-specific BMI percentiles. We used the Cochran-Armitage test to assess trends and the Jonckheere-Terpstra test to determine associations.

RESULTS

Of 446 subjects (acute recurrent pancreatitis, n = 241; CP, n = 205), 22 were underweight, 258 normal weight, 75 overweight, and 91 were obese. The BMI groups were similar in sex, race, and age at presentation. Hypertriglyceridemia was more common in overweight or obese. Obese children were less likely to have CP and more likely to have acute inflammation on imaging. Compared with children with normal weight, obese or overweight children were older at first acute pancreatitis episode and diagnosed with CP at an older age. Obese or overweight children were less likely to undergo medical or endoscopic treatment, develop exocrine pancreatic insufficiency, and require total pancreatectomy with islet autotransplantation. Diabetes was similar among all groups.

CONCLUSIONS

Obesity or overweight seems to delay the initial acute pancreatitis episode and diagnosis of CP compared with normal weight or underweight. The impact of obesity on pediatric CP progression and severity deserves further study.

Factors Associated With Length of Stay and 30-Day Revisits in Pediatric Acute Pancreatitis

OBJECTIVE

The objective of the study was to identify factors associated with length of stay (LOS) and 30-day hospital revisit for patients hospitalized with acute pancreatitis (AP).

METHOD

Multicenter, retrospective cohort study using the Pediatric Health Information System database. Multilevel linear and logistic regression was used to identify factors independently associated with the primary outcome variables of LOS and 30-day hospital revisit in children aged 1 and 18 years discharged with a primary discharge diagnosis of AP from participating hospitals between 2008 and 2013.

RESULTS

For the 7693 discharges, median LOS was 4 days (interquartile range 3-7 days) and 30-day revisit rate 17.6% (n = 1356). Discharges were primarily girls (55%), Caucasian (46%), and 6 years old or older (85%). On multilevel regression, factors independently associated with both longer LOS and higher revisit odds included malignant and gastrointestinal complex chronic conditions (CCCs) and total parenteral nutrition use while hospitalized. Male gender was associated with both lower LOS (adjusted length of stay = -0.6 days, 95% confidence interval [CI] = -0.8 to -0.4) and decreased revisit odds (aOR 0.85; 95% CI = 0.74 to 0.97). Hispanic ethnicity was associated with increased LOS (adjusted length of stay = +0.8 days, 95% CI = +0.5 to +1.1), but no change in revisit odds.

CONCLUSIONS

Certain demographic and clinical factors, including gender, ethnicity, and type of CCC, were independently associated with LOS and risk of 30-day hospital revisit for pediatric AP. Children with malignant and gastrointestinal CCCs who require total parenteral nutrition are at highest risk for both longer LOS and hospital revisit when admitted with AP. These patient populations may benefit from intensive care coordination when hospitalized for AP.

Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014

BACKGROUND & AIMS

Epidemiologic analyses of acute pancreatitis (AP) and chronic pancreatitis (CP) provide insight into causes and strategies for prevention and affect allocation of resources to its study and treatment. We sought to determine current and accurate incidences of AP and CP, along with the prevalence of CP, in children and adults in the United States.

METHODS

We collected data from the Truven MarketScan Research Databases of commercial inpatient and outpatient insurance claims in the United States from 2007 through 2014 (patients 0-64 years old). We calculated the incidences of AP and CP and prevalence of CP based on International Classification of Diseases, 9th Revision diagnosis codes. Children were defined as 18 years or younger and adults as 19 to 64 years old.

RESULTS

The incidence of pediatric AP was stable from 2007 through 2014, remaining at 12.3/100,000 persons in 2014. Meanwhile, the incidence for adult AP decreased from 123.7/100,000 persons in 2007 to 111.2/100,000 persons in 2014. The incidence of CP decreased over time in children (2.2/100,000 persons in 2007 to 1.9/100,000 persons in 2014) and adults (31.7/100,000 persons in 2007 to 24.7/100,000 persons in 2014). The prevalences of pediatric and adult CP were 5.8/100,000 persons and 91.9/100,000 persons, respectively, in 2014. Incidences of AP and CP increased with age. We found little change in incidence during the first decade of life but linear increases starting in the second decade.

CONCLUSIONS

We performed a comprehensive epidemiologic analysis of privately insured, non-elderly adults and children with AP and CP in the United States. Changes in gallstone formation, smoking, and alcohol consumption, along with advances in pancreatitis management, may be responsible for the stabilization and even decrease in the incidences of AP and CP.

Trans-heterozygosity for mutations enhances the risk of recurrent/chronic pancreatitis in patients with Cystic Fibrosis

BACKGROUND

Recurrent (RP) and chronic pancreatitis (CP) may complicate Cystic Fibrosis (CF). It is still unknown if mutations in genes involved in the intrapancreatic activation of trypsin (IPAT) or in the pancreatic secretion pathway (PSP) may enhance the risk for RP/CP in patients with CF.

METHODS

We enrolled: 48 patients affected by CF complicated by RP/CP and, as controls 35 patients with CF without pancreatitis and 80 unrelated healthy subjects. We tested a panel of 8 genes involved in the IPAT, i.e. PRSS1, PRSS2, SPINK1, CTRC, CASR, CFTR, CTSB and KRT8 and 23 additional genes implicated in the PSP.

RESULTS

We found 14/48 patients (29.2%) with mutations in genes involved in IPAT in the group of CF patients with RP/CP, while mutations in such genes were found in 2/35 (5.7%) patients with CF without pancreatitis and in 3/80 (3.8%) healthy subjects (p < 0.001). Thus, we found mutations in 12 genes of the PSP in 11/48 (22.9%) patients with CF and RP/CP. Overall, 19/48 (39.6%) patients with CF and RP/CP showed one or more mutations in the genes involved in the IPAT and in the PSP while such figure was 4/35 (11.4%) for patients with CF without pancreatitis and 11/80 (13.7%) for healthy controls (p < 0.001).

CONCLUSIONS

The trans-heterozygous association between CFTR mutations in genes involved in the pathways of pancreatic enzyme activation and the pancreatic secretion may be risk factors for the development of recurrent or chronic pancreatitis in patients with CF.

Recurrent Acute Pancreatitis: International State-of-the-Science Conference With Recommendations

Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.

Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group

OBJECTIVES

Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed.

METHODS

This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified.

RESULTS AND DISCUSSION

The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies.

CONCLUSIONS

This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.

Utility of CT classifications to predict unfavorable outcomes in children with acute pancreatitis

BACKGROUND

Computed tomography (CT) is useful for the diagnosis of local complications in children with acute pancreatitis but its role as a prognostic tool remains controversial.

OBJECTIVE

To establish the correlation between the CT Severity Index and the Revised Atlanta Classification regarding unfavorable outcomes such as severe acute pancreatitis and need for Pediatric Special Care Unit attention in children with acute pancreatitis.

MATERIALS AND METHODS

We conducted a retrospective and concordance cohort study in which we obtained abdominal CT scans from 30 patients ages 0 to 18 years with acute pancreatitis. Two pediatric radiologists interpreted the results using the CT Severity Index and the Revised Atlanta Classification. The kappa coefficient was determined for each scale. The association among severe acute pancreatitis, need for admission to the Pediatric Special Care Unit and CT systems were established using chi-square or Mann-Whitney U tests. The best CT Severity Index value to predict the need for admission to the Pediatric Special Care Unit was estimated through a receiver operating characteristic (ROC) curve.

RESULTS

Mean CT Severity Index was 5.1±2.8 (mean ± standard deviation on a scale of 0 to 10) for the severe acute pancreatitis group vs. 3.8±2.7 for the mild acute pancreatitis group (P=0.230). The CT Severity Index for the children who were not hospitalized at the Pediatric Special Care Unit was 2.2±2.2 vs. 5.6±2.4 for the group hospitalized at the Pediatric Special Care Unit (P=0.001). Only parenchymal necrosis >30% was associated with severe acute pancreatitis (P=0.021). A CT Severity Index ≥3 has a sensitivity of 89% and specificity of 72% to predict need for admission to the Pediatric Special Care Unit. None of the Revised Atlanta Classification categories was associated with severe acute pancreatitis or admission to the Pediatric Special Care Unit.

CONCLUSION

A CT Severity Index ≥3 in children with acute pancreatitis who require CT assessment based on clinical criteria is associated with the need for admission to the Pediatric Special Care Unit. We found that pancreatic necrosis greater than 30% is the only tomographic parameter related to severe acute pancreatitis. New studies with a greater sample size are necessary to confirm this result.

Pediatric chronic pancreatitis: Updates in the 21st century

Pediatric Pancreatitis has gained a lot of attention in the last decade. Updates in medical management include new testing technologies in genetics, function testing and imaging modalities. Updates in surgical management have taken place as well, with total pancreatectomy islet auto transplantation reserved for a specific patient population that meets the clinical criteria. Multidisciplinary team management is needed for patients with chronic pancreatitis to ensure optimal outcomes.

Amalgamation of systemic inflammatory response syndrome score with C-reactive protein level in evaluating acute pancreatitis severity in children

BACKGROUND AND AIM

Systemic inflammatory response syndrome (SIRS) has to do with how the body reacts to injury. Herein, we analyzed the clinical features of acute pancreatitis (AP) in children with SIRS complication and investigated the role of SIRS score combined with C-reactive protein (CRP) level in assessing AP severity in children.

METHODS

This retrospective cohort study involved 111 children hospitalized with AP at the Children's Hospital of Zhejiang University School of Medicine between January 2012 and August 2017. Presence of SIRS, demographic data, clinical information and laboratory test results on admission were statistically examined.

RESULTS

Out of the 111 AP cases, 45 were diagnosed with SIRS. Differences in CRP, interleukin-6 (IL-6), age, temperature, heart rate (HR), white blood cell (WBC), neutrophil count (NC), body mass index (BMI), duration of onset of disease symptoms as well as cases requiring intensive care unit (ICU) treatment were significantly higher in patients with SIRS than those without SIRS (p < .01 or p < .05). Logistic regression analyses evinced two independent risk factors for SIRS to be coexisted diseases (odds ratio (OR) = 4.871, p = .02) and fever (OR = 3.56, p = .007). SIRS was an independent predictor for AP severity (OR = 10.820, p = .005). The optimal cut-off value of CRP was 27.5 mg/L for severe AP classification according to receiver operating characteristic (ROC) (area under curve was 0.733).

CONCLUSION

Amalgamation of SIRS criterion with CRP level potentially plays an important role in assessing AP severity in children.

Multivariate Model for the Prediction of Severity of Acute Pancreatitis in Children

This study aimed to develop a severity prediction system for pediatric patients with acute pancreatitis (AP) based on clinical and laboratory parameters recorded at disease onset. A retrospective cohort study including 130 patients with AP, aged 0 to 18 years, was conducted. Correlations between severe AP (SAP) and clinical and laboratory data were established. Parameters with a significant statistical correlation (P ≤ 0.05) were incorporated in logistic regression models, and receiver operating characteristic curves were generated. The best-performance cutoff points were calculated to propose a severity prediction score, for which sensitivity and specificity were determined. Thirty-eight cases (29.2%) were consistent with SAP. A value of ≥1 point yielded a sensitivity of 81.5% and specificity of 64.1% for SAP prediction, when using a score including blood urea nitrogen ≥12.5 mg/dL (1 point) or hemoglobin <13 mg/dL (1 point) as variables. The proposed severity score showed good performance in predicting SAP.

Primary sclerosing cholangitis is associated with abnormalities in CFTR

BACKGROUND

The etiology of primary sclerosing cholangitis (PSC) is unknown. PSC and Cystic Fibrosis related liver disease have common features: chronic inflammation, biliary damage and similar cholangiographic findings. It is unknown whether or not PSC is related to cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction. We hypothesize that a sub-group of PSC patients may be a "single-organ" presentation of CF.

METHODS

Patients with PSC underwent nasal potential difference (NPD) measurement, sweat chloride measurement and complete CFTR sequencing by new generation sequencing.

RESULTS

6/32 patients aged 46 ± 13 yrs. had CFTR causing mutations on one allele and 19 had CFTR polymorphisms; 6/23 tested had abnormal and 21 had intermediate sweat tests; 4/32 patients had abnormal NPD. One patient had chronic pancreatitis and was infertile.

CONCLUSIONS

19% of PSC patients had features of CFTR related disorder, 19% carry CFTR mutations and 50% had CFTR polymorphisms. In some patients, PSC may be a single organ presentation of CF or a CFTR-related disorder.

An 18-Year-Old With Acute-on-Chronic Abdominal Pain

An 18-year-old woman with a complex past medical history presented with 2 days of vomiting and lower abdominal pain. She had been admitted for the majority of the previous 5 months for recurrent pancreatitis and had undergone a cholecystectomy. Additional symptoms included nausea, anorexia, constipation, and a 40-lb weight loss over 4 months. She appeared uncomfortable, and an examination was remarkable for tachycardia, hypertension, and diffuse abdominal tenderness to light palpation. Her initial laboratory test results revealed mildly elevated liver enzymes (aspartate aminotransferase 68 U/L, alanine aminotransferase 80 U/L) and a normal lipase. She was admitted for pain control and nutritional support. Over the next few days, the lipase increased to 1707 U/L. Despite optimizing her management for acute pancreatitis, the patient's symptoms persisted. Further history gathering and laboratory testing ultimately revealed her diagnosis. Our expert panel reviews her hospital course and elucidates the management of our eventual diagnosis.

Risk factors for pancreatitis after posterior spinal fusion in children with cerebral palsy

This study reports on the prevalence and risk factors of acute pancreatitis after posterior spinal fusion for cerebral palsy scoliosis. Pancreatitis diagnosis was based on elevated amylase or lipase above three times the upper normal limit. Perioperative data were compared between patients with and without pancreatitis. We included 300 patients; 55% developed acute pancreatitis. Gastrostomy dependence was more common in the pancreatitis group (P=0.048). Perioperative data were similar between groups. Patients with pancreatitis had longer duration of hospitalization (19 vs. 13 days, P<0.001). Acute pancreatitis is common after cerebral palsy scoliosis surgery. Gastrostomy dependence increases its risk. Although no mortality was reported, hospital stay was longer.

EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis

BACKGROUND

Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has increased, it is now 3.6-13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population.

METHODS

Pediatric Pancreatitis was divided into three main clinical categories: acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Fifteen relevant topics (acute pancreatitis: diagnosis; etiology; prognosis; imaging; complications; therapy; biliary tract management; acute recurrent pancreatitis: diagnosis; chronic pancreatitis: diagnosis, etiology, treatment, imaging, intervention, pain, complications; enzyme replacement) were defined. Ten experts from the USA and Europe reviewed and summarized the available literature. Evidence was classified according to the GRADE classification system.

RESULTS

Within fifteen topics, forty-seven relevant clinical questions were defined. The draft of the updated guideline was presented and discussed at the consensus meeting held during the 49th Meeting of European Pancreatic Club, in Budapest, on July 1, 2017.

CONCLUSIONS

These evidence-based guidelines provides the current state of the art of the diagnosis and management of pediatric pancreatitis.

Acute Pancreatitis Admission Trends: A National Estimate through the Kids' Inpatient Database

OBJECTIVES

To evaluate national health care use and costs for pediatric acute pancreatitis.

STUDY DESIGN

The Kids' Inpatient Database for 2006, 2009, and 2012 was queried for patients with a principal diagnosis of acute pancreatitis. Cases were grouped by age: preschool (<5 years of age), school age (5-14 years of age), and adolescents (>14 years of age).

RESULTS

A total of 27 983 discharges for acute pancreatitis were found. The number of admissions increased with age: young n = 1279, middle n = 8012, and older n = 18 692. Duration of stay was highest in preschool children (median, 3.47 days; IQR, 2.01-7.35), compared with school age (median, 3.22 days; IQR, 1.81-5.63) and adolescents (median, 2.87 days; IQR, 1.61-4.81; P < .001). The median cost of hospitalization varied with age: $6726 for preschoolers, $5400 for school-aged children, and $5889 for adolescents (P < .001). Acute pancreatitis-associated diagnoses varied by age. The presence of gallstone pancreatitis, alcohol, and hypertriglyceridemia was more common among older children compared with younger children (P < .001). There was an increasing trend in acute pancreatitis, chronic pancreatitis, and obesity for the 2 older age groups (P < .001).

CONCLUSION

Admission of children for acute pancreatitis constitutes a significant healthcare burden, with a rising number of admissions with age. However, the cost and duration of stay per admission are highest in young children.

Yield of Endoscopic Ultrasound in Children and Adolescent With Acute Recurrent Pancreatitis

OBJECTIVES

Endoscopic ultrasound (EUS) is an established tool for evaluation of adults with acute recurrent pancreatitis (ARP) whereas data in pediatrics is limited. Our study assessed the role of EUS in identifying etiology including changes of chronic pancreatitis (CP) in children and adolescents with ARP.

METHODS

Children with ARP (≥2 episodes of acute pancreatitis [AP]) were prospectively evaluated with a detailed clinical proforma and EUS. Subjects with known etiology of ARP or CP on ultrasonography/computed tomography and magnetic resonance cholangiopancreatography (MRCP, Cambridge grade ≥3) were excluded. Parenchymal and ductal changes on EUS as per minimal standards terminology (MST) features were noted.

RESULTS

Thirty-two children (22 boys, age 14 [8-18] years) with ARP (median of 3 [2-5] episodes of AP) were enrolled. EUS was safe and technically successful in all. Gall bladder sludge was found in 1 (3%) case and none had other pancreatobiliary structural abnormalities. EUS diagnosis of CP (≥4 features) was made in 10/32 (31%) cases. Subjects with CP on EUS had a longer disease duration than those without CP (45 [10-97] vs 22 [8-78] months; P = ns). MRCP was normal in 28 and showed pancreas divisum in 1 case. Three cases had equivocal (Cambridge II) changes at initial MRCP and 2 of them had repeat MRCP, which showed definite (Cambridge IV) CP. All these 3 cases had CP on EUS.

CONCLUSIONS

EUS diagnosed CP (≥4 features) in 31% and biliary abnormality in 3% children with ARP. EUS is safe, sensitive, and useful for early diagnosis of CP in children with ARP.

Etiology and clinical characteristics of pediatric acute pancreatitis in Saudi Arabia: a 20-year experience from a single tertiary center

Background

Cases of acute pancreatitis (AP) have increased among pediatric populations worldwide; however, the natural course of this condition in Saudi Arabia was unknown.

Aim

To report the characteristics as well as outcomes of pediatric AP.

Patients and methods

A retrospective chart review study was conducted to include acute pancreatitis in patients ≤ 19 years. The period was from 1994 until 2015. Demographic, clinical, laboratory, imaging and outcome data were collected and analyzed.

Results

50 patients (n = 26; 52% males vs. n = 24; 48% females) were included. The mean age at diagnosis was 11.6 years. The mean length of hospital stay was 10.5 days. 9 (18%) patients had a recurrence of AP and 4 (8%) had complications. Idiopathic AP was the most frequent etiology (n = 21; 42%), followed by cholelithiasis (n = 11; 22%). 2 patients (4%) had drug-induced AP, where one was taking isoniazid and the other had taken a large amount of erythromycin, amoxicillin and ibuprofen. 2 choledochal cysts complicated by AP (4%). Pancreaticobiliary diseases, as a complete entity, accounted for 34% (n = 17). Clinically, abdominal pain (n = 47; 94%) and vomiting (n = 38; 76%) were most commonly encountered. KUB was non-diagnostic in all patients. No patient died during their admission.

Conclusion

Although still relatively uncommon in Saudi Arabia, there are on average 2–3 cases of pediatric AP diagnosed annually in our institution. Idiopathic AP was the most common cause. Isoniazid and choledochal cysts are rare causes of AP and were reported in the study.

Initial Pain Management in Pediatric Acute Pancreatitis: Opioid Versus Non-opioid

Nearly all patients with acute pancreatitis (AP) experience some degree of abdominal pain that is severe enough to prompt medical evaluation and necessitate analgesia. Effective analgesia is a priority in caring for such patients. Despite its importance, strategies for pain management in AP have been poorly studied, particularly in the field of pediatrics. Presently, no published data examine the management of pain because of AP in children at the time of initial presentation. Management approaches are often extrapolated from adult practice and based on anecdotal experience in the absence of objective data. The aim of our study was to examine the initial provision of analgesia to children who presented to a pediatric emergency department with AP.

Risk Factors for Asparaginase-associated Pancreatitis: A Systematic Review

GOALS

To evaluate potential risk factors for the development of asparaginase-associated pancreatitis (AAP), we performed a systematic review of the current literature from January 1946 through May 2015.

BACKGROUND

Asparaginase, a primary treatment for the most common childhood cancer, acute lymphoblastic leukemia (ALL), is a well-described cause of pancreatitis. Further, pancreatitis is among the most burdensome and common complications of asparaginase treatment and represents a major reason for early-drug termination and inferior outcomes. The literature lacks clarity about the risk factors for AAP, and this knowledge gap has hampered the ability to reliably predict which patients are likely to develop AAP.

STUDY

In an expansive screen, 1842 citations were funneled into a review of 59 full articles, of which 10 were deemed eligible based on predetermined inclusion criteria.

RESULTS

Of the 10 identified studies, only 2 studies showed that children above 10 years of age had a >2-fold risk of AAP compared with younger children. Patients placed in high-risk ALL categories had a greater incidence of pancreatitis in 2 studies. In addition, use of pegylated asparaginase resulted in a higher incidence of AAP in 1 study.

CONCLUSIONS

In this systematic review, older age, asparaginase formulation, higher ALL risk stratification, and higher asparaginase dosing appear to play a limited role in the development of AAP. Further studies are needed to probe the underlying mechanisms contributing to the development of pancreatitis in patients receiving asparaginase.

S737F is a new CFTR mutation typical of patients originally from the Tuscany region in Italy

Background

An increasing number of patients have been described as having a number of Cystic Fibrosis Transmembrane conductance Regulator (CFTR) variants for which it lacks a clear genotype–phenotype correlation. We assesses the clinical features of patients bearing the S737F (p.Ser737Phe) CFTR missense variant and evaluated the residual function of CFTR protein on nasal epithelial cells (NEC).

Methods

A retrospective database was performed from individuals homozygous or compound heterozygous for the S737F variant followed in the Cystic Fibrosis (CF) Centre of Florence. We performed a nasal brushing in cooperating patients and compared the results with those of patients followed in the pediatric CF Centre of Naples.

Results

9/295 (3%) subjects carrying at least S737F CFTR variant on one allele were identified. Patients were diagnosed in 7/9 cases by newborn screening and in two cases for dehydration with hypochloremic metabolic alkalosis; at diagnosis sweat chloride levels (SCL) were in the pathological range in only one case. After a mean follow up of 8,6 years (range 0,5–15,8), SCL were in the pathological range in 8/9 cases (mean age at CF diagnosis: 1,5 years), all patients were pancreatic sufficiency and respiratory function was normal. The gating activity on NEC was 15.6% and 12.7% in two patients compound heterozygous for W1282X and DelE22_24, while it was ranged between 6,2% and 9,8% in CF patients.

Conclusions

S737F is a CFTR mutation associated to hypochloremic alkalosis in childhood, mild CF phenotype in teenage years and a residual function of CFTR protein.