Definitions of pediatric pancreatitis and survey of present clinical practices

Early Enteral Nutrition in Children With Acute Pancreatitis

Nutrition is an integral part of acute pancreatitis (AP) management and is not adequately studied in pediatrics. The goal from the present study was to evaluate the effect of nutrition and fat content on the length of stay and pain severity in patients with AP. This is a retrospective review of our nutrition database between May 1, 2014 and December 1, 2014. Pain levels were similar between patients who were allowed to feed and patients kept nill per os. Higher fat intake grams per kilogram per day was associated with significantly lower pain scores. Early feeds are feasible in pediatric patients with AP. Pain was not increased in the group that had more fat in their diet.

Direct Costs of Acute Recurrent and Chronic Pancreatitis in Children in the INSPPIRE Registry

OBJECTIVE

To estimate selected direct medical care costs of children with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP).

METHODS

We performed a cross-sectional study of data from International Study Group of Pediatric Pancreatitis: In Search for a Cure (INSPPIRE), a multinational registry of children with ARP or CP. We determined health care utilization and estimated costs of hospitalizations, surgical and endoscopic procedures, and medications in our study population. Health care utilization data were obtained from all subjects enrolled in the study, and costs were calculated using national United States costs.

RESULTS

We included 224 subjects (median age 12.7 years), 42% of whom had CP. Mean number of hospitalizations, including for surgery and endoscopic retrograde cholangiopancreatography, was 2.3 per person per year, costing an estimated average $38,755 per person per year. Including outpatient medications, estimated total mean cost was $40,589 per person per year. Subjects using surgical procedures or endoscopic retrograde cholangiopancreatography incurred mean annual costs of $42,951 per person and $12,035 per person, respectively. Estimated annual costs of pancreatic enzyme replacement therapy, diabetic medications, and pain medications were $4114, $1761, and $614 per person, respectively. In an exploratory analysis, patients with the following characteristics appear to accrue higher costs than those without them: more frequent ARP attacks per year, reported constant or episodic pain, family history of pancreatic cancer, and use of pain medication.

CONCLUSIONS

ARP and CP are uncommon childhood conditions. The severe burden of disease associated with these conditions and their chronicity results in high health care utilization and costs. Interventions that reduce the need for hospitalization could lower costs for these children and their families.

Acute Recurrent Pancreatitis in Children: A Study From the Pediatric Health Information System

We investigated acute recurrent pancreatitis (ARP) in children using a national health care database. From 2002 to 2014, 26,435 children had a diagnosis of acute pancreatitis (AP); 10,648 discharges were index hospitalizations. A total of 6159 children had a single hospitalization for AP, whereas 4489 (42%) children underwent 15,787 rehospitalizations. Children experienced a median of 2 ARP-related hospitalizations with a median time between admissions of 86 days. Younger patients with a more severe index episode of AP were at a higher risk of ARP. ARP-related hospitalizations had an increased requirement for intensive care unit care compared with an index episode of AP.

Acute pancreatitis as a complication of childhood cancer treatment

Acute pancreatitis (AP) is now well recognized as a possible complication of childhood cancer treatment, interrupting the chemotherapy regimen, and requiring prolonged hospitalization, possibly with intensive care and surgical intervention, thereby compromising the effect of chemotherapy and the remission of the underlying malignant disease. This review summarizes the current literature and presents the various etiological factors for AP during chemotherapy as well as modern trends in the diagnosis and therapy of AP in children.

Probing the Association of Pancreatitis in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) has been increasingly diagnosed in children and adults. Similarly, acute and chronic pancreatitis are increasingly prevalent conditions with potentially devastating consequences. There is a growing body of literature linking these 2 conditions. The purpose of this review is to provide a comprehensive outline of the association between IBD and pancreatitis and to explore their putative pathophysiology. Based on the collective reports, 2 outstanding reasons for pancreatitis in patients with IBD are medications and IBD complications.

Pancreatitis Subtypes Survey in 852 Childhood-Onset Systemic Lupus Erythematosus Patients

OBJECTIVE

Pancreatitis is a rare and a life-threatening systemic lupus erythematosus (SLE) manifestation in childhood-onset SLE (cSLE). The objective of this study was to systematically classify pancreatitis in cSLE according to the International Study Group of Pediatric Pancreatitis and determine the overall prevalence, clinical features, laboratory, and first episode outcomes.

METHODS

A multicenter cohort study in 10 pediatric rheumatology centers, including 852 patients with cSLE.

RESULTS

Pancreatitis was diagnosed in 22 of 852 (2.6%) patients with cSLE. It was classified as acute pancreatitis in 20 (91%), acute recurrent pancreatitis in 2 (9%), and none of them had chronic pancreatitis. None of them had gallstones, traumatic pancreatitis, or reported alcohol/tobacco use. The comparison of patients with pancreatitis (first episode) and without this complication revealed a shorter disease duration (1 [0-10] vs 4 [0-23] years, P < 0.0001) and higher median of Systemic Lupus Erythematosus Disease Activity Index 2000 (21 [0-41] vs 2 [0-45], P < 0.0001). The frequencies of fever (P < 0.0001), weight loss (P < 0.0001), serositis (P < 0.0001), nephritis (P < 0.0001), arterial hypertension (P < 0.0001), acute renal failure (P < 0.0001), macrophage activation syndrome (P < 0.0001), and death (P = 0.001) were also higher in patients with pancreatitis. The frequencies of intravenous methylprednisolone use (P < 0.0001) and the median of prednisone dose (55 [15-60] vs 11 [1-90] mg/day, P < 0.0001) were significantly higher in patients with pancreatitis. Of note, the 2 patients with acute recurrent pancreatitis had 2 episodes, with pain-free interval of 1 and 4 years.

CONCLUSIONS

This was the first study characterizing pancreatitis using the International Study Group of Pediatric Pancreatitis standardized definitions in patients with cSLE showing that the predominant form is acute pancreatitis seen in association with glucocorticoid treatment and active severe disease.

Variability in Pancreatitis Care in Pediatrics: A Single Institution's Survey Report

OBJECTIVE

The incidence of acute pancreatitis (AP) in childhood has increased in the last 2 decades, yet management has been largely extrapolated from adult studies. We sought to determine whether there is a consensus for treatment of AP among different pediatric subspecialists.

METHODS

Providers from subspecialties seeing most patients admitted for AP were surveyed on their practice patterns in managing a first attack of uncomplicated AP.

RESULTS

From November 2009 to August 2013, there were 284 admissions for patients with AP to our center. Patients were primarily admitted to the gastroenterology or hospitalist service (39% and 26%, respectively). Survey results found practice patterns for diagnostic evaluation, fluid resuscitation, pain management, and introduction of nutrition were variable between practitioners belonging to different subspecialties as well as within the same subspecialty group.

CONCLUSIONS

There is a lack of consensus on management of acute uncomplicated pancreatitis among pediatric providers, which may be improved through development of evidence-based pediatric guidelines.

Pain in the Early Phase of Pediatric Pancreatitis (PINEAPPLE Trial): Pre-Study Protocol of a Multinational Prospective Clinical Trial

BACKGROUND

There are unexpectedly large differences between the incidences of acute pancreatitis (AP) as indicated by different hospitals. Retrospective studies suggest that the reason behind this is the large differences that exist between the local managements of abdominal pain at emergency units. Unfortunately, no evidence-based medicine (EBM) guidelines are available to give proper instruction concerning the necessity of serum pancreatic enzyme measurement during abdominal pain.

SUMMARY

Pain in Early Phase of Pediatric Pancreatitis (PINEAPPLE) is an observational, multinational observational clinical trial to explore the route from the first sign of abdominal pain to the diagnosis of pancreatitis (PINEAPPLE trial). The PINEAPPLE-R subtrial is a retrospective review on the records of children (patients under 18) appearing at emergency units - a review of their clinical symptoms, results of imaging examinations and laboratory parameters. The PINEAPPLE-P subtrial is a prospective trial designed to develop a fast and simple EBM guideline that helps to evaluate (in a reliable and cost-efficient way) the necessity of pancreatic enzyme test and abdominal ultrasonography (or even computed tomography) when a child has abdominal pain. The trial has been registered at the ISRCTN registry and has received the relevant ethical approval.

KEY MESSAGE

The PINEAPPLE trial will help to recognize AP in children in a highly efficient manner.

Analysis of Pediatric Pancreatitis (APPLE Trial): Pre-Study Protocol of a Multinational Prospective Clinical Trial

BACKGROUND

Single-centered studies show increased number of acute pancreatitis (AP) in children. Here, the Pediatric Section of the Hungarian Pancreatic Study Group introduces an international observational clinical trial (APPLE) to collect a critical mass of clinical data and biomedical research samples in a uniform prospective manner.

SUMMARY

The APPLE-R is for patients under 18 years of age with a history of pancreatitis. The study primarily provides information on possible genetic variants behind the disease and their impact on the prognosis. The APPLE-P is for patients under 18 years of age with a diagnosis of AP. Children with AP diagnosed based on the fulfillment of '2 out of 3' of the Atlanta criteria will be selected. This subtrial requests detailed information from the medical history, etiology, complains and symptoms, physical examinations, laboratory parameters, imaging, immediate therapy at admission and complications of the disease. The APPLE trial has been registered at the ISRCTN registry and has received the relevant ethical approval. The study is open for all pediatric centers throughout the world.

KEY MESSAGE

This is the first worldwide study tracking earlier (APPLE-R) and ongoing episodes (APPLE-P) of pancreatitis.

Prevalence, Natural History, and Outcome of Acute Fluid Collection and Pseudocyst in Children With Acute Pancreatitis

OBJECTIVE

Recent years have witnessed an increase in acute pancreatitis (AP) in children; however, the natural history of acute fluid collection (AFC) and pseudocyst is largely unknown. We evaluated the frequency, clinical characteristics, and natural history of pseudocysts in children with AP.

METHODS

Children with AP admitted at Sanjay Gandhi Postgraduate Institute of Medical Sciences from 2001 to 2011 were enrolled and studied until complete resolution. Subjects with inadequate follow-up, recurrent AP, and chronic pancreatitis were excluded.

RESULTS

Of the 58 children (43 boys, median age 14 [1-18] years) with AP, 34 (58.6%) and 22 (38%) developed AFC and pseudocyst, respectively. No difference in age (12 [4-18] vs 13 [1-16] years), etiology (idiopathic 64% vs 47% and traumatic 27.2% vs 22.2%), and systemic complications (pulmonary [18% vs 11%], renal [22.7% vs 11%], and shock [13.6% vs 10%]) was observed between children with and without pseudocyst. A total of 11 of the 22 subjects with pseudocyst underwent drainage, the commonest symptom requiring drainage being gastric outlet obstruction [n = 5] and infection [n = 2]. The 11 of the 22 children with AP and pseudocyst (size 6.4 [3-14.4] cm) showed spontaneous resolution (disappearance [n = 9] and significant reduction in size [n = 2]) during 110 (25-425) days. Symptomatic pseudocysts requiring drainage were more often secondary to traumatic AP (6/6 vs 2/14 [idiopathic], P = 0.0007) than asymptomatic pseudocysts resolving spontaneously. Overall, only 26.4% (9/34) children with AFC required drainage because of symptomatic pseudocyst.

CONCLUSIONS

Among children with AP, 58.6% developed AFC and 38% developed pseudocysts. Only patients with symptomatic pseudocyst need drainage, and asymptomatic pseudocyst can be safely observed irrespective of size and duration of collection.

Paediatric pancreatitis

PURPOSE OF REVIEW

The purpose of this review is to describe recent developments in paediatric pancreatitis and to discuss causes and current management.

RECENT FINDINGS

Although recent studies have estimated the annual incidence of paediatric acute pancreatitis approaching that of adults, there are no established guidelines about its diagnosis and treatment in children. Genetic and structural/congenital abnormalities are emerging as the primary risk factors for paediatric acute recurrent and chronic pancreatitis. Specifically, chronic pancreatitis is associated with a significant socioeconomic burden in children. Both medical and surgical therapies are proposed for paediatric chronic pancreatitis, but there is little evidence that they are beneficial.

SUMMARY

Acute recurrent and chronic pancreatitis create significant health issues in the paediatric population. Medical and surgical therapies exist to potentially treat these conditions, but the paediatric data are limited and the cohorts are small. A multidisciplinary and multicentre approach is necessary to better determine pancreatic disease processes and treatment options in children.

Genetic predisposition and its impact on natural history of idiopathic acute and acute recurrent pancreatitis in children

BACKGROUND

Genetic predisposition in paediatric idiopathic acute, acute recurrent pancreatitis and its consequences are unknown. We studied frequency of genetic markers in acute, acute recurrent, chronic pancreatitis and their impact on natural history.

METHODS

Over a period of 2 years 68 consecutive children with pancreatitis (35.3% acute, 32.3% acute recurrent, 32.3% chronic) and 25 controls were recruited in a single centre. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease-inhibitor (PRSS1 R122H) and cystic fibrosis transmembrane conductance regulator (CFTR DeltaF508, 5T) were analysed.

RESULTS

Mean age was 13.4±2.5 years. Overall, 30 cases (SPINK1 N34S n=26, CFTR 5T n=4) and 1 control (SPINK1 N34S) had mutations (p=0.0001). The prevalence of SPINK1 N34S mutation was similar in chronic and acute recurrent pancreatitis (45%). Six children with severe acute pancreatitis had SPINK1 N34S mutations (25%, p<0.05), and 4 were homozygous. On follow-up 5 acute pancreatitis patients with mutations and 1 without mutations developed chronic pancreatitis (p=0.004); 8 cases of acute recurrent pancreatitis progressed to chronic pancreatitis (38%); of these 66.7% had mutations vs. 16.7% who did not (p=0.03).

CONCLUSIONS

Almost 50% of idiopathic chronic, acute recurrent and 33% of acute pancreatitis in children are genetically predisposed. Presence of genetic mutations in acute and recurrent acute pancreatitis increases the risk of developing chronic pancreatitis.

Pancreatic involvement in pediatric inflammatory bowel diseases

BACKGROUND

Inflammatory bowel diseases (IBDs) are a group of chronic diseases affecting the gastrointestinal tract, with a disabling course. The incidence of IBDs is increasing in different geographical areas, indicating its emergence as a global disease, especially in children. Many patients with IBDs develop extraintestinal manifestations (EIMs) during follow-up, as IBDs have a potential risk of systemic involvement..

DATA SOURCES

A systematic review of the literature was made to analyze latest studies on pancreatic involvement in children with IBD including our experience in assessing possible implications and its future application.

RESULTS

The involvement of the hepatobiliary system is considered a rare EIM of children with IBD, with an incidence much higher than that in the general population. Isolated pancreatic hyperenzymemia, which occurs in the absence of typical symptoms and/or characteristic imaging findings, may be found in many patients with IBD. The frequent causes of pancreatitis are drugs, bilio-pancreatic disorders, immunologic disturbances and pancreatic auto-antibodies, although in some cases idiopathic forms have been described.

CONCLUSIONS

It is important to establish a correct diagnostic approach based on etiology and to assess the most appropriate therapeutic strategy, thus avoiding complications and improving the quality of life of children with IBD.

ESPGHAN and NASPGHAN Report on the Assessment of Exocrine Pancreatic Function and Pancreatitis in Children

The purpose of this clinical report is to discuss several recent advances in assessing exocrine pancreatic insufficiency (EPI) and pancreatitis in children, to review the array of pancreatic function tests, to provide an update on the inherited causes of EPI, with special emphasis on newly available genetic testing, and to review newer methods for evaluating pancreatitis.

Possible Sulfamethoxazole/Trimethoprim-Induced Pancreatitis in a Complicated Adolescent Patient Posttraumatic Injury

Introduction:

Multiple medications have been associated with pancreatitis, however, data in the pediatric population are scarce secondary to the nonspecific presentation and infrequent diagnosis. The aim of this report is to characterize drug-induced pancreatitis in an adolescent patient.

Case Presentation:

A 16-year-old African-American female presented with a surgical site infection 8 weeks after a motor vehicle accident with multiple traumas. Two weeks prior to the admission, the patient was hospitalized for a urinary tract infection (UTI) and was initiated on sulfamethoxazole/trimethoprim (TMP/SMX) daily for UTI prophylaxis. On day 13, the patient was diagnosed with acute pancreatitis with an amylase level of 187 units/L (normal = 30-110) and a lipase level of 987 units/L (normal = 23-208). TMP/SMX was discontinued, and pancreatic enzyme levels decreased but did not reach normal. The patient was asymptomatic at discharge.

Discussion:

TMP/SMX was identified as the likely etiology of pancreatitis by the medical team. Evaluation with the Naranjo algorithm indicated a “possible” adverse drug reaction.

Conclusion:

Acute pancreatitis can have significant morbidity and mortality in the pediatric population but can go undiagnosed due to its lower incidence. Pediatric patients presenting with idiopathic abdominal pain should be evaluated for pancreatitis and drug therapy should be reviewed for potential causative agents.

Natural history of pancreatic involvement in paediatric inflammatory bowel disease

BACKGROUND

Few case reports describe the clinical features of pancreatic involvement in inflammatory bowel disease.

AIM

To investigate prevalence and disease course of inflammatory bowel disease children with pancreatitis and with exclusive hyperamylasemia and hyperlipasemia.

METHODS

We used a web-registry to retrospectively identify paediatric inflammatory bowel disease patients with hyperamylasemia and hyperlipasemia. Participants were re-evaluated at 6 months and 1 year.

RESULTS

From a total of 649 paediatric patients, we found 27 with hyperamylasemia and hyperlipasemia (4.1%). Eleven patients (1.6%) fulfilled diagnostic criteria for acute pancreatitis. Female gender was significantly associated with acute pancreatitis (p=0.04). Twenty-five children (92.5%) had colonic disease. At 6 months 1/11 children with acute pancreatitis (9%) showed acute recurrent pancreatitis, while 1 patient (9%) had persistent hyperamylasemia and hyperlipasemia. At 12 months, 1 patient showed chronic pancreatitis (9.1%). Of the 16 children with exclusive hyperamylasemia and hyperlipasemia, 4 developed acute pancreatitis (25%), while 1 patient (6.2%) still presented exclusive hyperamylasemia and hyperlipasemia at 6 months. At 12 months, 11/16 patients (68.7%) reached a remission of pancreatic involvement, whereas 5 remaining patients (32.3%) had persistent hyperamylasemia and hyperlipasemia.

CONCLUSIONS

In inflammatory bowel disease children, acute pancreatitis is more common in colonic disease and in female gender. Pancreatic function should be monitored, considering that pancreatic damage may evolve.

Genetic and electrophysiological characteristics of recurrent acute pancreatitis

OBJECTIVES

The aim was to present the workup of patients with acute recurrent pancreatitis (ARP) for genetic analysis and electrophysiological testing.

METHODS

Patients with ARP with unknown etiology were referred for genetic testing and evaluation of cystic fibrosis transmembrane conductor regulator (CFTR) function by nasal potential difference (NPD) testing.

RESULTS

A total of 67 patients were evaluated. The mean age was 23 ± 17 years (median 17.0 years, range 1.5-72 years); 90% were Jewish and 10% Arab. Ten (15%) patients carried PRSS1 gene mutation (K23R(7), R122H(2), and D21A(1)). One patient had K172E/- (chymotrypsin C [CTRC]) mutation, 1 had I42M (serine protease inhibitor Kazal type 1 [SPINK1])/V235I (CTRC) together with ΔF508/5T, 1 patient had R67H (SPINK1)/V235I (CTRC), and 1 patient had V235I (CTRC)/-. Ten of 67 (15%) patients submitted for CFTR gene testing carried mutations (ΔF508/L997F, ΔF508/5T(11TG), W1282/5T(12TG), W1282X/Y1014C, ΔF508/R31C, R117H/-, R117H/Y1014C, D1152H/-, 5T(11TG)/-, and L997F/-). Fifty-four (80%) patients underwent sweat testing. Of these, 5 had sweat chloride ≥60 mEq/L, and 22 patients had sweat chloride from 40 to 60 mEq/L. Of the 56 (83%) patients had nasal potential difference testing, 4 (6%) with abnormal results.

CONCLUSIONS

One-third (34%) of patients with ARP carry mutations for hereditary pancreatitis including rare mutations (K23R), and 12.5% have evidence of cftr mutations and 10% had CFTR dysfunction underscoring the importance of genetic and functional workup of these patients.

Pancreatitis and portal vein thrombosis in children: the chicken or the egg causality dilemma

BACKGROUND

The association of pancreatitis and portal vein thrombosis (PVT) is extremely rare in children. We report on 3 cases which suggest that there may be a causal relation between the two.

METHODS

Clinical characteristics and evolution of 3 children with this particular condition were analyzed retrospectively. In this group of patients, the strategy consisted in opting for early surgical decompression of the portal hypertension, which was followed by a favorable outcome, not only in terms of complications related to the portal hypertension but also of a contemporaneous spontaneous regression of the concurrent pancreatic disease, in absence of any other specific management of the latter problem.

RESULTS AND CONCLUSIONS

Combined PVT and pancreatitis is exceptional in children. Although this series is small, it provides insight and some evidence that the pancreatic disease might be secondary to the cavernomatous transformation of the regional venous system. More interestingly, it suggests that the appropriate management strategy should be to rapidly relieve portal hypertension after resolution of the acute phase of pancreatitis.

Predictors of severity in childhood pancreatitis: correlation with nutritional status and racial demographics

OBJECTIVE

Acute pancreatitis is one of the leading causes of rising pediatric hospitalizations in North America. The aim of this study was to assess the role of nutritional status and racial influences on the severity of acute pancreatitis in children.

METHODS

The institutional review board approved this retrospective chart review of children with the diagnosis of acute pancreatitis between the ages of 0 and 18 years hospitalized at the Johns Hopkins Hospital between 1998 and 2008. Parameters studied included biochemical markers associated with pancreatitis, review of severity of illness reflected through the length of stay, and pediatric intensive care unit admission.

RESULTS

The length of in-patient hospitalization was longer for children with imaging findings of pseudocyst or pancreatic necrosis (23.1 ± 26.4 days vs 4.4 ± 10.6 days; P = 0.0074) and malnourished children versus normal weight and obese children (16.5 days for malnourished vs 10.6 days for normal weight vs 10.7 days for obese; P = 0.04). There was also a significant difference in the need for pediatric intensive care unit admission across ethnic groups (18% African American vs 7% white) (P = 0.04).

CONCLUSIONS

Ethnicity and nutritional status may influence the severity and duration of hospitalization among children with pancreatitis.

Pediatric chronic pancreatitis is associated with genetic risk factors and substantial disease burden

OBJECTIVE

To determine the clinical presentation, diagnostic variables, risk factors, and disease burden in children with chronic pancreatitis.

STUDY DESIGN

We performed a cross-sectional study of data from the International Study Group of Pediatric Pancreatitis: In Search for a Cure, a registry of children with acute recurrent pancreatitis and chronic pancreatitis. Between-group differences were compared using Wilcoxon rank-sum test.

RESULTS

Among 170 subjects in the registry, 76 (45%) had chronic pancreatitis; 57% were female, 80% were white; median age at diagnosis was 9.9 years. Pancreatitis-predisposing genetic mutations were identified in 51 (67%) and obstructive risk factors in 25 (33%). Toxic/metabolic and autoimmune factors were uncommon. Imaging demonstrated ductal abnormalities and pancreatic atrophy more commonly than calcifications. Fifty-nine (77%) reported abdominal pain within the past year; pain was reported as constant and receiving narcotics in 28%. Children with chronic pancreatitis reported a median of 3 emergency department visits and 2 hospitalizations in the last year. Forty-seven subjects (70%) missed 1 day of school in the past month as the result of chronic pancreatitis; 26 (34%) missed 3 or more days. Children reporting constant pain were more likely to miss school (P = .002), visit the emergency department (P = .01), and experience hospitalizations (P = .03) compared with children with episodic pain. Thirty-three children (43%) underwent therapeutic endoscopic retrograde pancreatography; one or more pancreatic surgeries were performed in 30 (39%).

CONCLUSIONS

Chronic pancreatitis occurs at a young age with distinct clinical features. Genetic and obstructive risk factors are common, and disease burden is substantial.

[Pediatric pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]

Pediatric pancreatitis is a rare disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has been increased. The management of pediatric pancreatitis requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. In 8 clinical topics (diagnosis; etiology; prognosis; imaging; therapy; biliary tract management; complications; chronic pancreatitis) 50 relevant questions were defined. Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinical statements were accepted with total (more than 95%) agreement. The present Hungarian Pancreatic Study Group guideline is the first evidence based pediatric pancreatitis guideline in Hungary. The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care in pediatric pancreatitis and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

Clinical expression of patients with the D1152H CFTR mutation

BACKGROUND

Discordant results were reported on the clinical expression of subjects bearing the D1152H CFTR mutation, and also for the small number of cases reported so far.

METHODS

A retrospective review of clinical, genetic and biochemical data was performed from individuals homozygous or compound heterozygous for the D1152H mutation followed in 12 Italian cystic fibrosis (CF) centers.

RESULTS

89 subjects carrying at least D1152H on one allele were identified. 7 homozygous patients had very mild clinical expression. Over half of the 74 subjects compound heterozygous for D1152H and a I-II-III class mutation had borderline or pathological sweat test and respiratory or gastrointestinal symptoms; one third had pulmonary bacteria colonization and 10/74 cases had complications (i.e. diabetes, allergic bronchopulmonary aspergillosis, and hemoptysis). However, their clinical expression was less severe as compared to a group of CF patients homozygous for the F508del mutation. Finally, 8 subjects compound heterozygous for D1152H and a IV-V class mutation showed very mild disease.

CONCLUSIONS

The natural history of subjects bearing the D1152H mutation is widely heterogeneous and is influenced by the mutation in trans.

Innovation and hard work: The 2015 George E. Palade Medal Award Lecture

The George E Palade Medal is the highest honor awarded by the International Association of Pancreatology and is given to an individual who has made outstanding contributions to the understanding of the pancreas and pancreatic diseases. Professor David C Whitcomb, University of Pittsburgh, is the 2015 recipient. The Palade Lecture, presented in Shanghai, China on August 28, 2015, included 5 personal stories that provide perspective from a life-time of achievement: "My life in a nutshell"; "Two old ladies"; "7777"; "I helped put a man on the moon"; and "Rugby". Together, the stories provide encouragement to a younger generation, struggling to find their way as physicians and scientists who are working on pancreatic or other diseases in a challenging world.

Predictors for mortality following acute pancreatitis in children

INTRODUCTION

Although there are several studies focusing on pancreatitis etiology and clinical outcome, no previous report has examined the risk factors for death in children.

PATIENTS AND METHODS

We reviewed the medical records of all children (ages 0-18 years) admitted to West China Hospital with acute pancreatitis between 2002 and 2012. Independent predictors for death following acute pancreatitis in children were identified using a multivariate logistic regression analysis.

RESULTS

Biliary diseases (23%), medications (20%), idiopathic (19%), and trauma (11%) were the most common etiologies for acute pancreatitis in children. The death rate was 5% and the mean duration of hospital stay was 13 days. Organ failure during admission occurred in 24 of 371 patients and most of them started in 3 days of onset (19/24). Multivariate analysis with logistic regression confirmed that occurrence of SIRS in the first week of onset (OR = 2.12, 95% CI 1.14-6.32, P < 0.001), occurrence of organ failure within 3 days of onset (OR = 8.0, 95% CI 2.2-12.3, P < 0.001), occurrence of MOF in the first week of onset (OR = 9.4, 95% CI 2.3-14.6, P < 0.001), infected necrosis (OR = 1.28, 95% CI 1.08-1.52, P = 0.02), and idiopathic cause (OR = 17.3, 95% CI 2.0-60.5, P < 0.001) were independent risk factors for death in cases with pancreatitis.

CONCLUSIONS

Mortality rate and complication rate of acute pancreatitis in children remains low. Patients with SIRS, early organ failure, MOF, infected necrosis, or idiopathic cause should be well evaluated because they have higher risk of death.

Design and implementation of INSPPIRE

OBJECTIVES

Acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) are rare and poorly understood diseases in children. Better understanding of these disorders can only be accomplished via a multicenter, structured, data collection approach.

METHODS

The International Study Group of Pediatric Pancreatitis: In Search for a Cure (INSPPIRE) consortium was created to investigate the epidemiology, etiologies, pathogenesis, natural history, and outcomes of pediatric ARP and CP. Patient and physician questionnaires were developed to capture information on demographics, medical history, family and social history, medications, hospitalizations, risk factors, diagnostic evaluation, treatments, and outcome information. Information collected in paper questionnaires was then transferred into Research Electronic Data Capture (REDCap), tabulated, and analyzed.

RESULTS

The administrative structure of the INSPPIRE consortium was established, and National Institutes of Health funding was obtained. A total of 14 sites (10 in the United States, 2 in Canada, and 2 overseas) participated. Questionnaires were amended and updated as necessary, followed by changes made into the REDCap database. Between September 1, 2012 and August 31, 2013, a total of 194 children were enrolled into the study: 54% were girls, 82% were non-Hispanic, and 72% were whites.

CONCLUSIONS

The INSPPIRE consortium demonstrates the feasibility of building a multicenter patient registry to study the rare pediatric diseases, ARP and CP. Analyses of collected data will provide a greater understanding of pediatric pancreatitis and create opportunities for therapeutic interventional studies that would not otherwise be possible without a multicenter approach.

Pancreatitis in Children

Although the incidence of acute pancreatitis among children is less than that in adults, the physical and psychosocial impact on children and their families can be overwhelming. Pancreatitis is manifested as pain accompanied by a host of other complex issues. These issues are manifested more markedly when the patient has additional concomitant diagnoses. Pain management, liver function tests, amylase and lipase levels, endocrine and exocrine functionality, and recognition of systemic inflammation are especially important. Management after discharge from the hospital is often an ongoing stress for these patients and families, and multiple admissions to the intensive care unit may be necessary for feeding and pain complications. Presented in the context of an actual clinical case at a 500-bed tertiary care pediatric hospital, this patient’s scenario illustrates the importance of ensuring adequate nutrition, maintaining hydration, providing appropriate pain management, and preventing infection and thromboembolic events.

Update to the management of pediatric acute pancreatitis: highlighting areas in need of research

Acute pancreatitis is an emerging problem in pediatrics, with an incidence that is rising in the last 2 decades. Data regarding the optimal management and physician practice patterns are lacking. We present a literature review and updates on the management of pediatric pancreatitis. Prospective multicenter studies defining optimal management of pediatric pancreatitis are needed to guide care and improve outcomes for this patient population.

Diagnosing acute pancreatitis in children: what is the diagnostic yield and concordance for serum pancreatic enzymes and imaging within 96 h of presentation?

BACKGROUND/OBJECTIVES

There are limitations and challenges with the diagnosis of acute pancreatitis (AP) in children. We evaluated the diagnostic yield and concordance for serum pancreatic enzymes and imaging in children with AP.

METHODS

A retrospective review of laboratory and radiographic results within 96 h of AP presentation (January 2000-July 2011) was performed at two paediatric hospitals. Observed agreement and kappa statistics (κ) were determined between outcomes of bloods (lipase and/or amylase) and imaging (ultrasound (US) and/or computed tomography (CT)).

RESULTS

A total of 103/131 (79%) AP cases had both bloods and imaging performed (within 96 h). Overall, lipase, amylase, US and CT were consistent with an AP diagnosis in 93% (93/100), 54% (43/80), 27% (21/77) and 67% (28/42) of cases respectively. The diagnostic yield for combinations of blood(s) and imaging(s) tests was higher than any single test and blood tests alone. The observed agreement between bloods 'lipase or amylase' and imaging 'US or CT,' was 40%. The κ was -0.083 suggesting no agreement. In 55% of cases, enzymes were positive whilst imaging was negative and the converse was evident in 5% of cases. There was no agreement between the various diagnostic tests, except between amylase and US, which had fair agreement.

CONCLUSION

Elevations in serum lipase contributed to the diagnosis more often than other tests. Combinations of blood(s) and imaging(s) tests have an increased diagnostic yield. Serum enzyme elevation and imaging changes poorly correlated. At least 5% of cases of AP may be missed if imaging is not performed.

Epidemiology of acute pancreatitis in hospitalized children in the United States from 2000-2009

BACKGROUND

Single-center studies suggest an increasing incidence of acute pancreatitis (AP) in children. Our specific aims were to (i) estimate the recent secular trends, (ii) assess the disease burden, and (iii) define the demographics and comorbid conditions of AP in hospitalized children within the United States.

METHODS

We used the Healthcare Cost and Utilization Project Kids' Inpatient Database, Agency for Healthcare Research and Quality for the years 2000 to 2009. Extracted data were weighted to generate national-level estimates. We used the Cochrane-Armitage test to analyze trends; cohort-matching to evaluate the association of AP and in-hospital mortality, length of stay, and charges; and multivariable logistic regression to test the association of AP and demographics and comorbid conditions.

RESULTS

We identified 55,012 cases of AP in hospitalized children (1-20 years of age). The incidence of AP increased from 23.1 to 34.9 (cases per 10,000 hospitalizations per year; P<0.001) and for all-diagnoses 38.7 to 61.1 (P<0.001). There was an increasing trend in the incidence of both primary and all-diagnoses of AP (P<0.001). In-hospital mortality decreased (13.1 to 7.6 per 1,000 cases, P<0.001), median length of stay decreased (5 to 4 days, P<0.001), and median charges increased ($14,956 to $22,663, P<0.001). Children with AP compared to those without the disease had lower in-hospital mortality (adjusted odds ratio, aOR 0.86, 95% CI, 0.78-0.95), longer lengths of stay (aOR 2.42, 95% CI, 2.40-2.46), and higher charges (aOR 1.62, 95% CI, 1.59-1.65). AP was more likely to occur in children older than 5 years of age (aORs 2.81 to 5.25 for each 5-year age interval). Hepatobiliary disease was the comorbid condition with the greatest association with AP.

CONCLUSIONS

These results demonstrate a rising incidence of AP in hospitalized children. Despite improvements in mortality and length of stay, hospitalized children with AP have significant morbidity.

Acute pancreatitis in children: a tertiary hospital report

INTRODUCTION

The incidence of acute pancreatitis (AP) in children has increased significantly in the past two decades.

OBJECTIVE

All cases of AP, acute recurrent pancreatitis (ARP), and chronic pancreatitis examined between May 2002 and May 2012 at Hospital de Braga, Portugal, were reviewed.

MATERIAL AND METHODS

Patients were identified by searching the hospital's electronic discharge records for the International Classification of Disease, Ninth Revision (ICD-9) code 577.0 (acute pancreatitis). ARP was considered as two or more episodes of AP per year or more than three episodes over a lifetime with intervening return to baseline. The following data were analyzed: demographic information, clinical, laboratory and imaging test results, etiology of pancreatitis, medical and surgical management, length of hospitalization, and outcome. The clinical and laboratory factors used in the pediatric acute pancreatitis severity score system and computed tomography severity index (CTSI) score were compared between patients with mild and severe disease.

RESULTS

A total of 37 patients, 31 episodes of AP and 6 patients with ARP, were documented. The most prevalent etiologies were biliary stones/sludge (24.3%) and trauma (16.2%). Admission elevated white blood cell count (p=0.011), 48-h trough calcium (p=0.007), and 48-h rise in blood urea nitrogen (p=0.025) correlated significantly with disease severity. CTSI on admission had a score below 4 in three patients with severe disease.

CONCLUSION

This Portuguese pediatric pancreatitis report highlights the multiple and complex etiology of this disease. Better pediatric scoring systems and management algorithms are needed.

Prediction of acute pancreatitis risk based on PIP score in children with cystic fibrosis

BACKGROUND

Currently no tools to predict risk of acute (AP) and recurrent pancreatitis (ARP) in children with cystic fibrosis (CF) are available. We assessed the prevalence of AP/ARP and tested the potential role of Pancreatic Insufficiency Prevalence (PIP) score in a cohort of children with CF.

METHODS

We identified two groups of children, on the basis of presence/absence of AP/ARP, who were compared for age at diagnosis, clinical features, genotypes and sweat chloride level. PIP score was calculated for each patient.

RESULTS

10/167 (5.9%) experienced at least one episode of AP during follow up; 10/10 were pancreatic sufficient (PS). Patients with AP/ARP showed a PIP score ≤0.25 more frequently (6/10) than patients without AP/ARP. The odds ratio (95% CI) of developing pancreatitis was 4.54 (1.22-16.92) for patients with PIP <0.25 when compared with those who have a PIP score >0.25 (p 0.0151). PIP score was correlated with sweat chloride test (p < 0.01).

CONCLUSION

PIP score, PS status and normal/borderline sweat chloride levels could be applied to predict pancreatitis development in children with CF. ARP could lead to pancreatic insufficiency.

Predicting a biliary aetiology in paediatric acute pancreatitis

OBJECTIVE

Acute biliary pancreatitis (ABP) is a common cause of pancreatitis which may require timely intervention. We aimed to identify routine laboratory parameters for early prediction of biliary aetiology in paediatric acute pancreatitis (AP).

DESIGN

A retrospective review of children with AP (January 2000-July 2011) was performed at two tertiary paediatric hospitals in New South Wales, Australia. Predictors of ABP using laboratory parameters (measured within 48 h of presentation) were determined using a multivariate logistic regression model and evaluated.

RESULTS

Of the 131 pancreatitis episodes reviewed, 21 (16%) were biliary-related. Raised serum lipase, alkaline phosphatase, γ-glutamyl transpeptidase (GGT), alanine aminotransferase (ALT) and aspartate aminotransferase were associated with biliary aetiology (all p<0.0016) on univariate analysis. In multiple logistic regression, serum GGT ≥40 U/L, ALT ≥150 U/L, and lipase ≥15 × the upper limit of normal (ULN) were predictive of ABP. To improve clinical applicability, the predictive performance when at least two of the three ABP predictors (coined the 'biliary pancreatitis triad') were satisfied was evaluated. The triad performed with a specificity, sensitivity, positive predictive value and negative predictive value of 95, 89, 76 and 98%, respectively.

CONCLUSIONS

The biliary pancreatitis triad of serum GGT ≥40 U/L, ALT ≥150 U/L and lipase ≥15×ULN within 48 h of presentation may be used as simple clinical predictors of ABP in children. Children with values falling below 2 or 3 of these thresholds are very unlikely to have AP due to a biliary cause.

Contrasts and comparisons between childhood and adult onset acute pancreatitis

Acute pancreatitis (AP) in children is an increasingly recognised clinical entity notably different from the adults with respect to incidence, aetiology, severity and outcome. Yet our current understanding and approach to the management of paediatric pancreatitis is based almost entirely on adult studies. Acute recurrent pancreatitis (ARP) in children is more likely associated with various genetic factors, some of which have been relatively well characterised and others are in an evolving phase. The aim of this review is to summarise current knowledge, highlight any recent advances and contrast the paediatric and adult forms of this condition.

Serum lipase as an early predictor of severity in pediatric acute pancreatitis

OBJECTIVES

Pediatric pancreatitis remains poorly understood despite increasing incidence and risk of morbidity and mortality. Present predictive scores for severe pediatric acute pancreatitis (AP) are either extrapolated from adults or difficult to use in practice. We aimed to identify laboratory parameters for early prediction of severity of the course of pediatric AP.

METHODS

A retrospective review of children with AP (January 2000-July 2011) was performed at 2 pediatric hospitals. Predictors of severe AP using laboratory parameters measured within 24 hours of presentation were derived in the cohort from one institution and validated in the other.

RESULTS

A total of 131 pancreatitis episodes, 73 (34% severe) and 58 (24% severe) in the derivation and validation cohorts respectively, were reviewed. In the derivation cohort, serum lipase was significantly higher in severe versus mild AP (median [interquartile range] 18.1 [9.2-39.1] vs 4.9 (3.2-13.3) × upper limit of normal [ULN]; P = 0.002). Logistic regression analysis in the derivation cohort showed serum lipase ≥7 × ULN to be predictive of severe AP. This finding was confirmed in the validation cohort. Based on the combined derivation and validation data, serum lipase ≥7 × ULN was associated with an odds ratio of 7.1 (95% confidence interval 2.5-20.5; P < 0.001) for developing severe AP. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were 85%, 56%, 46%, 89%, 1.939, and 0.27, respectively.

CONCLUSIONS

Serum lipase ≥7 × ULN within 24 hours of presentation may be a simple clinical predictor of severe AP in children. Lipase levels below this threshold are strongly associated with a milder course.

Acute necrotizing pancreatitis in children

OBJECTIVE

To describe the etiologic factors, course, and outcome of acute necrotizing pancreatitis in children.

STUDY DESIGN

We performed a retrospective study of children with necrotizing pancreatitis diagnosed during the last 21 years at Yale-New Haven Children's Hospital. Computed tomography (CT) criteria were used to diagnose necrotizing pancreatitis and to assess severity index. Charts were reviewed to collect demographics, etiology, details of hospital stay, complications, and outcome.

RESULTS

Seven children (mean age, 11.6 years; range, 4-17.8 years) had necrotizing pancreatitis. Etiologic factors were medications, diabetes, and gallstones. All had prolonged hospitalization (9-40 days; mean, 20 days) and 5 patients required admission to the pediatric intensive care unit. During the hospital stay, patients developed complications involving the respiratory, hematologic, renal, metabolic, and circulatory systems. All patients had aggressive supportive medical therapy, and none required surgery. There were no deaths attributable to pancreatitis. Late complications after hospital discharge occurred in 5 patients and included pseudocysts, transient hyperglycemia, diabetes, and pancreatic exocrine insufficiency. The CT severity index correlated with the risk of complications.

CONCLUSIONS

A cute necrotizing pancreatitis has a variable etiology in children. CT scan is useful in the diagnosis and assessment of severity. Necrotizing pancreatitis in children is associated with severe acute and late complications and requires intensive medical therapy.

Acute and recurrent pancreatitis in children: exploring etiological factors

OBJECTIVE

Etiologies of acute pancreatitis (AP) in children are more variable than in adults, including drugs, traumas, infections and multisystem disorders as well as biliary anomalies. While causes of pancreatitis have been extensively analyzed, different series reported different causes. The aims of this study were: 1) to assess the etiological factors of acute and recurrent pancreatitis in a pediatric population from a tertiary care hospital; 2) to assess the usefulness of imaging studies in diagnosing etiologies of pancreatitis.

MATERIAL AND METHODS

Thirty-four children (median age 11 years, 23 males) with AP and 11 with recurrent pancreatitis were retrospectively studied to assess etiology of pancreatitis in children.

RESULTS

The most common etiologies of AP were medications (11/34) and biliary tract diseases (9/34), whereas systemic diseases accounted for a small percentage of case. Among patients with recurrent episodes, biliary anomalies were the most common cause (6/11), whereas only 2 out of 11 patients with recurrent pancreatitis presented a hereditary cause.

CONCLUSIONS

This study highlights that etiologies of AP in children are variable. Epidemiology of AP could be influenced by single center's characteristics. Anatomic anomalies should be ruled out and genetic causes should be considered in recurrent cases.