Acute pancreatitis in children and adolescents

Potential Predictors of Severe and Recurrent Pancreatitis in Children: A Single-Center Experience

OBJECTIVES

Severe pancreatitis often requires intensive care; therefore, early detection is important. This study aimed to evaluate the possible predictors of pancreatitis severity in children. Furthermore, we evaluated the prevalence of pancreatitis recurrence and related factors.

METHODS

We retrospectively analyzed the medical records of patients aged younger than 18 years who were diagnosed with acute pancreatitis between January 2017 and June 2022. Acute pancreatitis was diagnosed and classified based on the revised Atlanta criteria.

RESULTS

A total of 64 patients were enrolled, and severe pancreatitis was observed in 10 (15.6%) patients. Patients with severe pancreatitis were younger and had higher C-reactive protein levels than those with mild pancreatitis. The areas under the receiver operating characteristic curves of C-reactive protein levels at admission and 48 hours after diagnosis were 0.612 (95% confidence interval, 0.379-0.844) and 0.873 (95% confidence interval, 0.537-0.983), respectively. Fourteen patients (21.9%) experienced further episodes of recurrent pancreatitis. Patients with recurrent pancreatitis were older (13.7 vs 11.4 years, P = 0.022) and prominently boys (85.7 vs 52%, P = 0.022) compared with those without recurrence. Obesity was observed in 4 (0.6%) patients, which was confirmed in all recurrence groups and was statistically significant.

CONCLUSIONS

This study demonstrated the feasibility of C-reactive protein in the early risk assessment of patients with acute pancreatitis and highlighted the potential risk of recurrence in patients with obesity.

Acute pancreatitis in childhood - a comparative international study and tale of two cities

BACKGROUNDS

To compare factor(s) contributing to aetiology, management and clinical outcome(s) of paediatric patients acquiring acute pancreatitis (AP) at two major university paediatric surgical centres in Liverpool and Bangkok.

METHODS

All patients (<18 years) with an index diagnosis of AP (ICD 10 coding) during 2006-2016 were studied.

RESULTS

121 patients included n = 79 (65.3%) in Thailand versus n = 42 (34.7%) in the UK centre with no difference(s) in age at diagnosis at 10.4 ± 4.5 and 11.7 ± 6 years. (P = 0.12). Major AP aetiology(s) in Thailand were medications (39.2%) and choledochal cysts (8.9%). In the UK-gallstone disease (21.4%), and medications (16.7%) were leading factors (P < 0.01). Ultrasonography was deployed more frequently in the UK versus Thai centre (74.3% vs. 49.1%; P < 0.01). Pancreatitis was confirmed by imaging in 67.9% (Thai) and 62.9% (UK) patients (P = 0.47). Most patients at both centres had a mild-grade pancreatitis illness (95% Thai vs. 90.5% UK; P = 0.28) while 12.7% of Thai and 19% of UK children developed pancreatitis-related complication (P = 0.37). Overall mortality rate (%) was significantly higher in the Thai versus UK centre (27.8% vs. 9.5%; P = 0.02).

CONCLUSIONS

Aetiology of acute pancreatitis appears to vary between UK and Thailand children. Timely early diagnosis and healthcare pathways may be driven by local patient-related factor(s). The higher mortality (%) observed in Thailand versus UK in this comparative study was linked to underlying co-existent chronic medical condition(s) in vulnerable patient cohorts.

Acute pancreatitis in children: risk factors, management, and outcomes

PURPOSE OF REVIEW

Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis.

RECENT FINDINGS

Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis.

SUMMARY

The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.

The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents

Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

Pediatric Pancreatic Endocrine Tumor Presenting as Acute Pancreatitis: A Case Report

Pancreatic neuroendocrine tumors (PNETs) are relatively rare, especially in the pediatric age group. This report describes a pediatric case of acute pancreatitis secondary to stenosis of the main pancreatic duct due to a PNET. The patient was a boy, thirteen and a half years old, who presented with persistent low-grade fever, nausea, and abdominal pain. He was diagnosed with acute pancreatitis based on the elevation of serum pancreatic enzyme levels and abdominal ultrasonography findings of enlargement of the pancreas and dilatation of the main pancreatic duct. Abdominal contrast-enhanced computed tomography (CT) showed a 5.5 mm, contrast-enhanced mass in the head of the pancreas. His symptoms resolved with conservative treatment, although the pancreatic tumor grew slowly. At fifteen years and four months, since the tumor had enlarged to 8.0 mm, the patient underwent pancreaticoduodenectomy for therapeutic and diagnostic purposes. Based on the pathological evaluation, he was diagnosed with PNET (grade: G1). The patient has been free of tumor recurrence for 10 years and requires no additional therapy. In this report, the clinical characteristics of PNETs are also discussed, comparing the clinical features of adult-onset and pediatric-onset cases that initially present as acute pancreatitis.

Pancreatitis in the Complex Care Population: Presentation, Incidence, and Severity

OBJECTIVES

To describe the incidence and presentation of pancreatitis in Children with Medical Complexity (CMC) while evaluating severity of disease and outlining risk factors.

METHODS

This was a retrospective chart review between January 2010 and December 2019 of patients seen in the complex care clinic at Nationwide Children's Hospital (NCH) and Cincinnati Children's Hospital Medical Center (CCHMC). Data collected included sex, underlying diagnosis, family history of pancreatitis, type of pancreatitis, signs/symptoms, abdominal imaging, severity of attack, and presence of various risk factors associated with pancreatitis. Severity and diagnosis of pancreatitis was determined based on North American Society for Pediatric Gastroenterology, Hepatology and Nutrition criteria.

RESULTS

One hundred and twelve patients from both institutions were included, 62% from NCH, median age 11.5 [interquartile range (IQR): 5-16 years], 50% male. Most patients were less than 18 years of age with a median age of 8 years (IQR: 4-13 years). Underlying diagnoses included seizures (67%), cerebral palsy/spastic quadriplegia (65%), diabetes (3.6%), and mitochondrial disease (3%). Majority of patients were found to have multiple underlying diagnoses (88%). Incidence of pancreatitis for both institutions was 336 of 100,000 patients/year which is significantly higher than the general pediatric population ( P < 0.0001). Majority of first episodes of pancreatitis were mild (82%) with abdominal pain as the predominant symptom (50%). Adult patients were more likely to have pancreatitis related to medication use than pediatric patients (70% vs 38%, respectively P = 0.007).

CONCLUSIONS

Individuals in the CMC population at our institutions have a high incidence of pancreatitis with unique risk factors compared to the general pediatric/young adult populations.

Acute Pancreatitis in Childhood: A 10-Year Experience From A Thai University Surgical Center

OBJECTIVES

This study aimed to describe etiology, management, and health outcomes of children developing acute pancreatitis at a tertiary Thailand pediatric surgery center.

METHODS

Medical case records of all index cases during 2006-2016 were analyzed and reported.

RESULTS

There were 42 male and 37 female patients, with a mean (standard deviation) age of 10.4 (4.5) years, included in the study. Medications were the commonest etiology for 39.3% of acute pancreatitis attacks, 11.4% for biliary tract disease cases, and 8% for postinterventional studies. In 30% of cases, no cause(s) was defined. Sixty-two patients (78.5%) had elevated serum lipase on hospital admission, whereas only 30.4% showed a raised amylase. Hospital stay was 15 days (interquartile range, 6-27 days). Two major complications in the series were pseudocysts (8.8%) and necrotizing pancreatitis (7.6%). Etiological factors and/or antibiotics were not directly linked to any specific complications. Seventeen children (22.8%) had 1 recurrent episode of acute pancreatitis documented. Mortality rate in index cases was 28%, with a higher percentage harboring a preexisting illness (34.4% vs 5.6%; P = 0.01) and in male than in female patients (41% vs 14%; P = 0.01).

CONCLUSIONS

Deaths from pediatric acute pancreatitis are more prevalent in male individuals and those with a preexisting illness. Targeted strategies aimed at "highest-risk" patients may potentially offset mortality.

Acute pancreatitis in children with acute lymphoblastic leukemia correlates with L-asparaginase dose intensity

BACKGROUND

L-Asparaginase (L-Asp) is an important therapeutic for childhood acute lymphoblastic leukemia (ALL). Asparaginase-associated pancreatitis (AAP) is a severe complication of L-Asp related to the dosage. We investigated the incidence of, and risk factors for, AAP in pediatric patients with ALL.

METHODS

From January 2002 to December 2018, pediatric patients with ALL treated at National Taiwan University Hospital were enrolled in this study. The diagnosis of AAP was based on the criteria of the Ponte di Legno Toxicity Working Group.

RESULTS

Of the 353 patients enrolled in this study, 14 (4.0%) developed AAP. The incidence of AAP in ALL patients was significantly higher after treatment with the 2013 protocol compared with the 2002 protocol of the Taiwan Pediatric Oncology Group (9.5% vs. 1.3%). Multivariate analysis showed that a high peak L-Asp dose intensity (>45,000 U/m²/month) and older age at diagnosis (>6.8 years) were independently predictive of AAP development.

CONCLUSIONS

The incidence of acute pancreatitis in childhood ALL was correlated more strongly with the peak dose intensity than with the cumulative dose of L-Asp. These results could be used to reduce the treatment-related complications of ALL.

IMPACT

L-Asparaginase is an important therapeutic for childhood acute lymphoblastic leukemia, and the accumulated dosage of L-asparaginase is considered as a major risk factor of asparaginase-associated pancreatitis. This article demonstrated that the incidence of pancreatitis correlates with the dose-intensity of L-asparaginase, but not the accumulated dosage. Identification of patient group with high risk of pancreatitis could lead to early diagnosis and reduce the complication. This finding could aid in developing further new protocol or therapeutic strategy design to reduce treatment-related complications and improve clinical outcomes of childhood acute lymphoblastic leukemia.

Risk Factors, Clinical Features, and Outcomes of Acute Pancreatitis in Children in Endemic Zone of Ascariasis in Eastern Bihar: A Hospital-Based Study

Objective

This study aims to describe the etiology, clinical features, and outcomes of acute pancreatitis (AP) in children in an endemic area of hepatobiliary ascariasis.

Methods

This retrospective observational study included acute pancreatitis (AP) patients in the age group of 2-15 years from January 2019 to January 2022. Demographic profile, risk factors, clinical features, laboratory imaging, and outcome data were collected and analyzed.

Results

A total of 40 patients comprising of 21 males (52.5%) and 19 females (47.5%) were included. The median age of the diagnosis of AP was 8.3 years (range: 4-14 years). Biliary ascariasis was the most frequent etiology of AP (n=18, 45%), followed by gallbladder (GB) stone (n=6, 12%), trauma (n=1, 2.5%), hepatitis (n=1, 2.5%), valproate drug (n=1, 2.5%), and GB sludge (n=1, 2.5%). In clinical features, all cases had pain in the abdomen (n=40, 100%), followed by fever (n=9, 22.5%), nausea/vomiting (n=33, 82.5%), jaundice (n=2, 5%), and anemia (n=2, 5%). Three (7.5%) patients developed complications such as shock, pseudocyst, and necrotizing pancreatitis, respectively. The average median hospital stay was nine days (range: 4-20 days). No mortality occurred in our study.

Conclusions

This study revealed a high prevalence (12-13 cases/year) of AP in children in this area. Biliary ascariasis (45%) emerged as the commonest risk factor. Most of the cases suffered from mild AP (92%) and so recovered completely without any complication.

Primary hypertriglyceridemia induced pancreatitis in a cohort of Pakistani children

OBJECTIVES

Primary hypertriglyceridemia is a rare condition in children. Hypertriglyceridemia induced pancreatitis is most commonly reported in adults, accounting for third most common cause after gallstones and alcohol consumption. The study aims to highlight the frequency of hypertriglyceridemia induced pancreatitis in a cohort of children presenting in a tertiary care hospital.

METHODS

A retrospective review of paediatric patients with pancreatitis was conducted in Shifa International hospital, Islamabad, from 2013 to 2020. All patients under 18 years of age who fulfilled the inclusion criteria were included. Medical records of patients were checked for symptoms, signs, age, growth parameters and laboratory investigations. Patients who had HTG were reviewed in detail for family history of pancreatitis or dyslipidemias.

RESULTS

We found a cohort of 6 patients with primary hypertriglyceridemia after excluding secondary causes. Out of these 6 patients, 4 (66.6%) were male and 2 (33.3%) were female. Minimum age of our patient was 2 months and maximum was 17 years with a mean age of 6.5 years. Two patients presented less than one year of age. Mean triglyceride levels was 1,599 + 523 mg/dL. Four patients (66.6%) had acute pancreatitis, one each (16.6%) had recurrent and chronic pancreatitis. Family history was positive for hyperlipidaemia in two patients who had positive consanguinity. Patients with positive family history were symptomatic at earlier age.

CONCLUSIONS

This is the first study to highlight primary hypertriglyceridemia presenting as pancreatitis in paediatric population from Pakistan. All patients had triglycerides level of greater than 1000 mg/dL.

Minimally Invasive Parathyroidectomy in a Child With Acute Pancreatitis

Acute pancreatitis (AP) is rarely seen in the paediatric population and is typically not associated with those aetiologies seen in adult pancreatitis. This case describes a 12-year-old female who presented with acute abdominal pain and constipation, with biochemical evidence of elevated serum amylase, calcium (Ca) and parathyroid hormone (PTH) levels. A diagnosis of AP was made, which was settled with conservative management. Further investigations, namely CT and technetium 99m (Tc-99m) sestamibi scans, revealed a solitary parathyroid adenoma. She subsequently underwent minimally invasive parathyroidectomy (MIP), following which Ca and PTH levels normalized postoperatively.

Case Report: Splanchnic Vein Thrombosis as a Complication of Necrotizing Acute Pancreatitis in a Pediatric Patient

Splanchnic vein thrombosis is an unusual manifestation of venous thromboembolism and includes portal vein thrombosis, mesenteric veins thrombosis, splenic vein thrombosis, and the Budd-Chiari syndrome. The most common risk factors include hematologic and autoimmune disorders, hormonal therapy, liver cirrhosis, solid abdominal cancer, recent abdominal surgery, and abdominal infections or inflammatory conditions, such as pancreatitis. Splanchnic vein thrombosis in acute pancreatitis is most commonly associated with the severe form of the disease and pancreatic necrosis. This report describes a case of splanchnic vein thrombosis as a complication of necrotizing acute pancreatitis in a pediatric patient. Splanchnic vein thrombosis was incidentally detected on contrast-enhanced computed tomography to assess the pancreas. There was no evidence of prior risk factors for the thrombotic condition. The patient was treated with anticoagulation and showed complete resolution after recovery from necrotizing acute pancreatitis, at a 16-month follow-up. The complication of necrotizing acute pancreatitis with splanchnic vein thrombosis in pediatric age is a rare presentation.

Clinical Characteristics and Short-Term Outcomes of Children With Asparaginase-Associated Pancreatitis

OBJECTIVES

Acute pancreatitis is a significant toxicity of l-asparaginase, a chemotherapeutic agent used to treat acute lymphoblastic leukemia. This case series describes the short-term clinical course and disposition of patients who developed asparaginase-associated pancreatitis (AAP) at one quaternary pediatric center.

METHODS

Clinical data, including laboratory data, inpatient and intensive care unit (ICU) days, imaging findings, presence of complications such as need for ventilation, dialysis, and the development of pleural effusions, and mode of nutrition were abstracted from the medical record of patients with AAP. Pediatric criteria were used to classify episode severity based on the development of organ failure and local complications, such as pancreatic necrosis.

RESULTS

Between 2005 and 2015, 34 patients had AAP with 43 distinct episodes of pancreatitis. The median inpatient length of stay was 10 days (range 2-65). Seven episodes (16.3%) required intensive care unit (ICU)-level care. Seventeen episodes (39.5%) were severe based on the development of organ failure or presence of pancreatic necrosis. Total parenteral nutrition (TPN) was used in 17 episodes (39.5%); for 34 episodes (79.1%), patients were discharged on entirely oral feeds. Antibiotics were administered in 20 episodes (46.5%). Pancreatic necrosis was identified within the first week in 12 episodes (27.9%). There were no deaths due to AAP.

CONCLUSIONS

The clinical course varies widely among patients with AAP. Over one-third of the patients in this series developed severe pancreatitis. Although the prognosis of AAP is generally good, many patients develop systemic complications of AAP, requiring TPN or ICU-level care.

Hereditary pancreatitis: An updated review in pediatrics

Hereditary Pancreatitis (HP) has emerged as a significant cause of acute, acute recurrent and chronic pancreatitis in the pediatric population. Given that it presents similarly to other causes of pancreatitis, a positive family history and/or isolation of a gene mutation are vital in its designation. Inheritance patterns remain complex, but mutations involving the PRSS1, SPINK1, CFTR and CTRC genes are commonly implicated. Since being first described in 1952, dozens of genetic alterations that modify the action of pancreatic enzymes have been identified. Among children, these variants have been isolated in more than 50% of patients with chronic pancreatitis. Recent research has noted that such mutations in PRSS1, SPINK1 and CFTR genes are also associated with a faster progression from acute pancreatitis to chronic pancreatitis. Patients with HP are at increased risk of developing diabetes mellitus, exocrine pancreatic insufficiency, and pancreatic adenocarcinoma. Management follows a multi-disciplinary approach with avoidance of triggers, surveillance of associated conditions, treatment of pancreatic insufficiency and use of endoscopic and surgical interventions for complications. With significant sequela, morbidity and a progressive nature, a thorough understanding of the etiology, pathophysiologic mechanisms, diagnostic evaluation, current management strategies and future research considerations for this evolving disease entity in pediatrics is warranted.

International Survey on Severe Acute Respiratory Syndrome Coronavirus 2 and Acute Pancreatitis Co-occurrence in Children

OBJECTIVES

It is unknown to what extent coronavirus 2019 (COVID-19) may co-occur with acute pancreatitis (AP) in children and how their clinical course may differ from children with AP alone.

METHODS

An online survey was sent to pediatric gastroenterologists to report on COVID-19 and AP cases from December 11, 2020, to February 26, 2021.

RESULTS

From 72 respondents (20 countries, 5 continents), 22 cases of positive COVID-19 infection and AP were reported. Patients were predominantly White or Hispanic/Latinx (73%), female (68%), and adolescents (68%). For 86% of patients, this was their first episode of AP. Sixty-eight percent of positive COVID-19 tests were polymerase chain reaction based. There was significant morbidity; 60% required intensive care, 45% had multiorgan involvement, and 24% developed shock. Eleven percent had pancreatic necrosis. Abnormal clotting and systemic inflammatory laboratories were common (31%-92% and 93%, respectively). Median length of symptomatic pancreatitis recovery was 1.8× longer than AP without COVID-19.

CONCLUSIONS

Coronavirus 2019 infection and AP co-occur primarily in children without a prior history of pancreatitis. Given the increased need for intensive care, multiorgan involvement, and potentially higher risk for pancreatic necrosis, pediatric providers should have a high level of suspicion for AP in children with COVID-19 infection.

Sporadic Burkitt Lymphoma Presenting with Middle Cranial Fossa Masses with Sphenoid Bony Invasion and Acute Pancreatitis in a Child

Acute pancreatitis in children is usually due to infection, trauma, or anatomical abnormalities and is rarely due to obstruction from malignancy. Sporadic Burkitt lymphoma (BL) is an aggressive non-Hodgkin B-cell lymphoma that usually involves the bowel or pelvis, with isolated cases presenting as acute pancreatitis. We report a case of BL in a 12-year-old male presenting as acute pancreatitis with obstructive jaundice and a right middle cranial fossa mass invading the sphenoid bone. The common bile duct in this case was dilated to 21 mm in diameter on abdominal ultrasound and to 26 mm on magnetic resonance cholangiopancreatography (MRCP), significantly greater than any value reported in the literature for BL. Given the rapidly progressing nature of BL, we emphasize the importance of recognizing heterogeneous presentations of this disease to improve patient survival. We also conclude that it is important to consider malignancy in a child with acute pancreatitis, particularly in the presence of obstructive jaundice or multisystem involvement. Other Presentations. This case report has no prior publications apart from the abstract being accepted to the 2020 SIOP (International Society of Pediatric Oncology) meeting and 2020 ASPHO conference (canceled due to the COVID-19 pandemic) and subsequently published as an abstract only in Pediatric Blood and Cancer. We have also presented the abstract as a poster presentation at our institution's (NYU Langone Hospital—Long Island, previously known as NYU Winthrop) annual research day conference in 2020.

A Practical Approach to Management of Acute Pancreatitis: Similarities and Dissimilarities of Disease in Children and Adults

Acute pancreatitis (AP) is associated with significant morbidity and mortality, and it substantially contributes to the healthcare burden of gastrointestinal disease and quality of life in children and adults. AP across the lifespan is characterized by similarities and differences in epidemiology, diagnostic modality, etiologies, management, adverse events, long-term outcomes, and areas in greatest need of research. In this review, we touch on each of these shared and distinctive features of AP in children and adults, with an emphasis on recent advances in the conceptualization and management of AP.

Acute Pancreatitis in Children: The Clinical Profile at a Tertiary Hospital

Objectives The clinical course and progression of acute pancreatitis are poorly understood to date, necessitating more studies of clinical profiles during the disease. Moreover, understanding the etiologies and clinical presentations of acute pancreatitis (AP) in children can contribute to early diagnosis and, hence, earlier interventions. Therefore, this article aims to study the clinical profiles of children with acute pancreatitis (AP) in relation to complications and other variables. Study design We retrospectively studied 56 patients who presented with AP to the pediatric department in Salmaniya Medical Complex between January 2006 and December 2017. Cases of chronic pancreatitis and ages above 12 years were excluded. The data concerned demographics, etiology, clinical data, hospital course, and outcomes. Results The study included 56 patients aged a mean of 8.46 years (male:female - 33:23). The average hospital stay was 7.68 days. Patients received parenteral feeds a mean of 2.77 days. All patients had an ultrasound, nine required CT scans (16.1%), and five MRIs (8.9%). There were 18 local complications (32.1%): pseudocysts (n=3, 5.36%), cholangitis (n=2, 3.6%), and edema (n=13, 23.2%). There were 23 intensive care unit (ICU) admissions (41.1%). No mortalities occurred but there were six recurrences (10.7%). Symptoms of abdominal pain, vomiting, fever, and nausea occurred in 100%, 57.1%, 35.7%, and 23.2% of patients, respectively. Etiologies were 41.1% biliary, 23.2% idiopathic, 19.6% traumatic, and 8.93% drug-induced. Leukocytes were elevated in 20 patients (35.7%), c-reactive protein (CRP) in five (8.93%), serum amylase in 45 (80.4%), and urinary amylase in all 56 patients (100%). Conclusion Most pediatric AP cases were attributed to biliary causes followed by trauma. Age was significantly correlated with complication rates (P=0.013). Abdominal pain was a more common symptom than vomiting. Leukocytosis was associated with ICU admissions. There was no significant relation between c-reactive protein, serum amylase, or urinary amylase, and complications or ICU admissions. Pediatric AP was self-limiting and there were no fatalities.

Endoscopic Ultrasonography in Pediatric Patients with Pancreatobiliary Disease: Single-Center Trial

PURPOSE

The use of Endoscopic ultrasonography (EUS) in pediatric patients is not as common as in adults. The aim of this study is to evaluate the role of EUS in the diagnosis of pancreatobiliary disease in childhood.

METHODS

Between December 2016 and January 2018, the findings of patients who underwent EUS were evaluated retrospectively.

RESULTS

Of the 41 patients included in the study 25 were girls (61.0%), mean age was 12.2±4.2 years. EUS was performed for biliary colic in 21 (51.2%), for recurrent pancreatitis in 12 (29.2%), for cholecystitis/cholangitis in 5 (12.2%), and for acute pancreatitis in 3 (7.4%) patients. EUS had a significant clinical effect in the decision of treatment and follow-up of 6/21 biliary colic cases, in diagnosis and follow-up of 6/12 recurrent pancreatitis cases, in decision-making and monitoring of invasive procedures (ERCP/surgery) of 3/5 acute cholecystitis/cholangitis and 2/3 of acute pancreatitis cases as well as in follow-up of the other cases. The effectiveness of EUS in determining direct treatment and invasive intervention was 43.9%. None of the patients had complications related to the EUS procedure.

CONCLUSION

Although current guidelines show that EUS can be used in pediatric patients, this is limited to a few published studies. In this study, it is shown that EUS is a safe method for the diagnosis, follow-up and treatment of common pancreatobiliary pathologies in childhood.

Burkitt Lymphoma Presenting as Acute Pancreatitis: Report of 3 Cases and Review of the Literature

Acute pancreatitis is a rare presentation in Burkitt lymphoma (BL) and may lead to delayed medical or unnecessary surgical treatment. Three cases of BL presenting as acute pancreatitis in the authors' institutions were described. Similar cases reported in the medical literature were collected and described along with the authors' cases. There were 12 cases described in the medical literature and hence a total of 15 cases of BL presenting as acute pancreatitis. Fourteen cases were the first diagnosis, and the other presented at lymphoma relapse. Twelve cases occurred in children under 15 years. Twelve patients had extrapancreatic disease. Three children were treated with surgery before diagnosis. Two patients died. Six of the remaining had adequate follow-up and were surviving in remission 8 months to 16 years after diagnosis. Lymphoma should be included in the differential diagnosis of acute pancreatitis in children. Acute pancreatitis in combination with malignant infiltration on imaging is highly suggestive of BL, especially in the jaundiced child.

Management of pancreatic pseudocysts in pediatric oncology patients

BACKGROUND

Management of children with pancreatic pseudocysts has historically been adopted from the adult experience where pancreatic pseudocysts greater than 6 cm are unlikely to resolve without intervention. We reviewed the clinical course of pediatric oncology patients with pancreatic pseudocysts.

METHODS

A retrospective review of patients treated over a 15-year period was performed. Variables evaluated included cancer type, medications administered, clinical and imaging characteristics of the pancreatic pseudocysts, treatment and outcome.

RESULTS

A total of 132 patients with a median age of 13 (IQR, 9-17) years were identified with pancreatitis. Thirty-one (23.5%) patients developed a pancreatic pseudocyst, of which 84% were associated with PEG-asparaginase treatment. The median pseudocyst size was 7.6 (IQR, 4.4-9.9) cm with 59% being greater than 6 cm. Twenty-two (71%) patients with a pancreatic pseudocyst underwent successful conservative management, while only 9 (29%) required procedural intervention including six percutaneous drainage, one of whom recurred and required surgical cyst-enteric drainage. Two other patients had primary surgical cyst-enteric drainage and one patient underwent endoscopic retrograde cholangiopancreatography with stenting. The indication for intervention was worsening pain rather than pseudocyst imaging characteristics, size or serum amylase/lipase.

CONCLUSION

Most medication-induced pancreatic pseudocysts in children being treated for cancer, regardless of pseudocyst size, can be managed non-operatively or with transgastric percutaneous drainage. The need for intervention can be safely dictated by patient symptoms.

LEVEL OF EVIDENCE

III.

Microbial lipases and their industrial applications: a comprehensive review

Lipases are very versatile enzymes, and produced the attention of the several industrial processes. Lipase can be achieved from several sources, animal, vegetable, and microbiological. The uses of microbial lipase market is estimated to be USD 425.0 Million in 2018 and it is projected to reach USD 590.2 Million by 2023, growing at a CAGR of 6.8% from 2018. Microbial lipases (EC 3.1.1.3) catalyze the hydrolysis of long chain triglycerides. The microbial origins of lipase enzymes are logically dynamic and proficient also have an extensive range of industrial uses with the manufacturing of altered molecules. The unique lipase (triacylglycerol acyl hydrolase) enzymes catalyzed the hydrolysis, esterification and alcoholysis reactions. Immobilization has made the use of microbial lipases accomplish its best performance and hence suitable for several reactions and need to enhance aroma to the immobilization processes. Immobilized enzymes depend on the immobilization technique and the carrier type. The choice of the carrier concerns usually the biocompatibility, chemical and thermal stability, and insolubility under reaction conditions, capability of easy rejuvenation and reusability, as well as cost proficiency. Bacillus spp., Achromobacter spp., Alcaligenes spp., Arthrobacter spp., Pseudomonos spp., of bacteria and Penicillium spp., Fusarium spp., Aspergillus spp., of fungi are screened large scale for lipase production. Lipases as multipurpose biological catalyst has given a favorable vision in meeting the needs for several industries such as biodiesel, foods and drinks, leather, textile, detergents, pharmaceuticals and medicals. This review represents a discussion on microbial sources of lipases, immobilization methods increased productivity at market profitability and reduce logistical liability on the environment and user.

Acute pancreatitis in children: Updates in epidemiology, diagnosis and management

Acute pancreatitis (AP), manifesting as acute onset of abdominal pain, vomiting, and nausea, is increasingly being recognized in children secondary to increased awareness, more identifiable etiologies as well as advances in diagnostic capabilities, like imaging. Despite this increased awareness and ability for more frequent diagnoses, the natural history of AP remains poorly understood leading to gaps in approach and management, especially in children. Coupled with poor epidemiologic and management awareness, there remains a lack of understanding of the long term implications of severe acute pancreatitis (SAP). Hence, the role of the primary care clinician in the early diagnosis, and management, remains critical and may affect the need for consultation with pediatric sub-specialists like gastroenterologists. This review provides guidelines regarding epidemiology, diagnosis, and management strategies to address some of these gaps.

Posaconazole-Induced Acute Pancreatitis: A Rare Side Effect in a Child with Chronic Granulomatous Disease

Introduction: Pancreatitis is an inflammatory disease of the pancreas. Drug-induced pancreatitis is an important cause of pancreatitis. There are two pathological types of acute pancreatitis, including pancreatic edema with a mild course and pancreatic necrosis with a poor prognosis. Some agents can induce pancreatitis, but so far, posaconazole-induced pancreatitis in children has been not reported. Here, we describe the case of a child with acute pancreatitis who received posaconazole. Case Presentation: A 10-year-old girl with a three-year history of chronic granulomatous disease (CGD) was admitted to hospital due to epigastric pain, nausea, vomiting, loss of appetite, and fever for the last four days. The pain was persistent and prominent in the periumbilical area. The patient was on lifelong antifungal prophylaxis for her illness. On abdominal sonography, the head of the pancreas was inflated, which can indicate pancreatitis. All the medications were discontinued at the time of admission, and along with sufficient hydration, acetaminophen was administered for the patient’s pain. One, three, and twelve months after discharge, the patient was visited for follow-up with no signs of stomach discomfort, and the lab data was within the normal limits. CGD is a rare disease in which the phagocytes fail to produce hydrogen peroxide. Such patients are prone to bacterial and fungal infections. Conclusions: In conclusion, this is the second case of posaconazole-induced pancreatitis and the first case in children; thus, we recommend that physicians should be aware of the signs of pancreatitis in high-risk individuals like immunocompromised pediatric population.

A single-center analysis of primary nephrotic syndrome with acute pancreatitis in children

Primary nephrotic syndrome (PNS) is one of the most common primary glomerular diseases in children. Patients complicated nephrotic syndrome with pancreatic lesions are rarely reported, and the clinical manifestations in children are atypical. This study has observed the incidence, clinical types, and prognosis of acute pancreatitis (AP) in children with primary nephrotic syndrome, and analyzed its related factors, early diagnosis, and treatment.Seven children with PNS and AP in Shanghai Children's Hospital from January 2015 to December 2017 were reviewed. The clinical data including age, height, weight, body mass index (BMI), diet, biliary tract disease, PNS durations, drugs, proteinuria, creatinine, glucose, glycated hemoglobin, amylase and lipase, albumin, cholesterol, triglyceride, ultrasound, computerized tomography (CT), renal pathology and estimated glomerular filtration rate (eGFR) were retrospectively analyzed. All patients were followed for >2 years.Ten in 589 patients with PNS were detected pancreatic lesions by abdominal ultrasound. Seven were diagnosed as AP, which the incidence was 1.2%. Only 1 of 7 patients had elevated serum amylase. Lesions of pancreas were found by ultrasound and/or enhanced CT. Four of 7 patients had been treated with tacrolimus. All patients with AP were improved after octreotide acetate injection and supportive treatment. Only 1 patient suffered recurrent AP during the relapse of PNS 10 months later.AP in children with PNS is not common, and the clinical manifestations are not typical. Abdominal ultrasound and enhanced CT are of high value in diagnosis. The adverse effects of tacrolimus should be concerned. Early diagnosis and timely treatment can be helpful for a prognosis.

Separate pancreatic ducts draining into a type IV choledochal cyst: simultaneous anatomical variants in a child suffering from cholelithiasis and acute pancreatitis

The biliary tree and the pancreatic ducts originate from different buds of the primitive foregut. A plethora of anatomical variants and congenital anomalies have been described for both the biliary and the pancreatic duct systems, although they are usually asymptomatic. However, in some cases, these abnormalities can lead to serious clinical scenarios, especially when involving the biliopancreatic junction, with consequent mixing and reflux of the two different juices. To the best of our knowledge, we present the first case of pancreas divisum ducts draining into a choledochal cyst, with the lower third of the choledochus configuring a common biliopancreatic duct, in a child suffering from cholelithiasis and acute pancreatitis.

Meandering Main Pancreatic Duct in Association with Choledochal Cysts and Acute Pancreatitis in Pediatrics

Meandering main pancreatic duct (MMPD) is an uncommon anomaly of the main pancreatic duct characterized by an abnormal curvature at the pancreatic head region. This variant can be diagnosed on imaging, particularly magnetic resonance cholangiopancreatography (MRCP). Although its clinical significance remains debatable, recent research suggests an association with recurrent acute pancreatitis. To our knowledge, no pediatric cases of acute or recurrent acute pancreatitis have been attributed to the presence of MMPD. In this article, we report on two patients. The first case is of a 15-year-old girl with MMPD discovered on investigation of idiopathic acute pancreatitis. The second case is of a 5-year-old boy who presented with his second episode of acute pancreatitis. In this patient, MRCP imaging revealed MMPD and type IVA choledochal cyst. With appropriate care, both patients experienced clinical improvement with resolution of abdominal pain. This article highlights MMPD as a distinct entity that should be considered in pediatric patients with recurrent attacks of acute pancreatitis. This report also describes the first association of MMPD with choledochal cysts. [Pediatr Ann. 2019;48(10):e412-e416.].

Acute pancreatitis in children on chronic maintenance dialysis

Patients on dialysis are exposed to a series of factors that are known to be associated with risk of acute pancreatitis (AP), including medications, hyperparathyroidism, hypercalcemia, and hypertriglyceridemia; the role of the dialysis modality itself is still debated. Data regarding AP in children on chronic dialysis are scarce. Data from the Italian Registry of Pediatric Chronic Dialysis (IRPCD) confirm that children on dialysis have a significant increased relative risk (RR) for AP as compared with the general pediatric population (RR 60.4; 95% CI 3.2-214). Diagnosis of AP in patients on dialysis may be troublesome, because it can mimic other acute intraabdominal conditions and the role of serum pancreatic enzyme assays may be confounding. In this setting, instrumental imaging is mandatory. Conservative management such as fluid, bowel rest, and antibiotics is the mainstay of AP management, as necrotizing forms are rare. Mortality in the series of 12 patients from the IRPCD was high (25%), but deaths were not directly related to AP. Adult case series confirm that mortality among patients on dialysis who develop AP is highly variable (8-58%), but higher as compared to 10% mortality from AP in non-renal failure patients.

Clinical features of acute pancreatitis in people of different age groups: A retrospective analysis

BACKGROUND

Acute pancreatitis (AP) is one of the common causes of acute abdomen in clinical practice. In the past, patients with AP were mostly young adults. However, in recent years, with the growth and aging of our country's population, the incidence of AP in the elderly and children is also on the rise. The clinical manifestations of AP at different age groups are slightly different due to their physiological characteristics. The clinical manifestations of elderly and children are atypical, which can easily lead to misdiagnosis and missed diagnosis.

AIM

To analyze the clinical features of AP in people of different age groups.

METHODS

In this retrospective clinical trial, 1758 cases of AP were enrolled from January 2003 to June 2016, and they were divided into three groups according to age: <18, 18-60, and ≥ 60 years old. The general clinical data, etiology, severity of AP, complications, clinical course, prognosis, and biochemical criteria for AP were summarized in different age groups.

RESULTS

In the < 18 age group, the incidence of AP in male patients (53.8%) was slightly higher than that of females (46.2%); the proportion of mild AP (MAP) (78.5%) was higher than those the other two groups; and the rates of complications and mortality were significantly lower than those of the other two groups (P < 0.05). In the 18-60 age group, the incidence of AP in male patients (71.0%) was higher than that of the other two groups (P < 0.05); the incidence of alcoholic and hyperlipidemic pancreatitis (13.4%, 21.5%) was higher than that of the other two groups (P < 0.05); the incidence of pancreatic necrosis in this group of patients was the highest (23.4%); and the rates of peripancreatic exudation, pleural effusion, acute respiratory distress syndrome, and acute renal insufficiency (54.3%, 36.9%, 5.6%, and 6.5%, respectively) were significantly higher than those of the < 18 age group (P < 0.05). In the ≥ 60 age group, the incidence of AP in male patients (57.7%) was slightly higher than that in females (42.3%); the rate of nausea (58.2%) was significantly higher than those of the other two groups (P < 0.05); the incidence of biliary pancreatitis (61.2%) was the highest (P < 0.05); and the proportion of patients with moderately severe AP (43.5%) was higher than those of the other two groups (P < 0.05). The patients in the < 18 age group had the longest hospital stay (17.97 ± 12.14 d; P < 0.05). The proportion of patients staying in the intensive care unit and the mortality rate in the ≥ 60 age group were the highest (4.1% and 13.1%, respectively; P < 0.05). There was no difference in hospitalization cost among patients of different age groups (P > 0.05). There was no significant difference in peripheral blood leukocyte count among the three groups (P > 0.05). Mean C-reactive protein level in the < 18 age group was higher than those of the other two groups. Serum amylase was higher in the ≥ 60 age group than in the < 18 age group. Lipase (LPS) in the ≥ 60 age group was higher than those of the other two groups (P < 0.05), and mean LPS did not differ significantly between the18-60 and < 18 age groups (P > 0.05).

CONCLUSION

The incidence of alcoholic and hyperlipidemic pancreatitis is higher in middle-aged people. Elderly patients with AP are most prone to nausea, and the mortality rate is the highest. When young people have unexplained vomiting and bloating, AP should be suspected.

A Rare Cause of Acute Hepatopancreatitis in a Nepalese Teen

Background

Acute pancreatitis (AP) coexisting with acute hepatitis (AH) in children is uncommon. Moreover, a single bacterial cause explaining both the complications is even rarer. Despite familiarity with the usual presentation of enteric fever, atypical presentations can go unnoticed.

Case Presentation

A 16-year-old previously healthy male presented to the emergency unit with recurrent swinging pyrexia, abdominal symptoms, and jaundice for a week. Blood work-up revealed deranged liver function tests (LFTs) and elevated pancreatic enzymes. Further assessment with imaging made a diagnosis of AH and AP without necrosis. Blood culture positivity for Salmonella typhi eventually confirmed the diagnosis.

Conclusion

This is an uncommon presentation of an infection that is fairly common in our part of globe. Nevertheless, early suspicion and recognition is the key to timely management. Regular follow-ups are required to pick complications up early.

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.

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.

The emerging role of endoscopic ultrasound for pancreaticobiliary diseases in the pediatric population

BACKGROUND

Endoscopic ultrasound (EUS) is a useful diagnostic and therapeutic tool in the pediatric population. Given the high accuracy and sensitivity of EUS, it is particularly effective in evaluating pancreaticobiliary disease. Published literature in the use of pediatric EUS is limited. Therefore we aimed to review the current literature for EUS indications, safety, and effectiveness for the pediatric population.

DATA SOURCES

English language articles on the use of pediatric endoscopic ultrasound in evaluating pancreaticobiliary diseases were retrieved from PubMed/ MEDLINE.

RESULTS

We analyzed various retrospective studies and case series publications. Data were extrapolated for pediatric patients with pancreaticobiliary diseases.

CONCLUSIONS

EUS offers superior imaging. It is comparible to magnetic resonance imaging and/or pancreatic-protocol computed tomography. In the current literature, there are a variety of pancreaticobiliary conditions where EUS was utilized to make a diagnosis. These include recurrent pancreatitis, congenital anomalies, microlithiasis, pancreatic pseudocysts, and pancreatic mass lesions. EUS was shown to be a safe and cost-effective modality with both diagnostic and therapeutic capabilities in the pediatric population. EUS is now increasingly being recognized as a standard of care when evaluating pancreaticobiliary conditions in children.

Fentanyl Ameliorates Severe Acute Pancreatitis-Induced Myocardial Injury in Rats by Regulating NF-κB Signaling Pathway

Background

Acute pancreatitis (AP) is a sudden inflammation of the pancreas. It results in multiple, severe complications, and 15–20% of patients develop severe acute pancreatitis (SAP) with mortality as high as 30%. Consequently, it is imperative to develop an effective therapy for SAP.

Material/Methods

We used 30 adult male Sprague Dawley (SD) rats. Rats were randomly divided into 3 groups – sham, SAP, and fentanyl+SAP – with 10 rats in each group. An automatic biochemical analyzer was used to analyze the concentration of creatine kinase isoenzyme (CK-MB) and lactate dehydrogenase (LDH). Terminal-deoxynucleotidyl transferase-mediated nick-end labeling (TUNEL) assay was applied to assess the cell apoptosis rate. Pathological changes in pancreas/heart were detected with hematoxylin and eosin (HE) staining. Western immunoblot assay was used to analyze protein levels of interleukin (IL)-1β, IL-6, and IκB.

Results

Fentanyl pre-treatment inhibits SAP-induced elevation of CK-MB/LDH concentrations in serum. Compared with the sham group, SAP generates a higher brown/yellow staining rate, which is abated by fentanyl. In the pancreas, SAP generated more serious interstitial edema/hemorrhage and fat necrosis than in the sham group, which are attenuated by fentanyl. Likewise, compared to the sham group, SAP generates swelled/disordered myocardial fibers and congested blood vessels in myocardium, which are ameliorated by fentanyl. In the sham group, there was little IL-1β/IL-6, and fentanyl significantly inhibited SAP-induced up-regulation of IL-1β/IL-6 levels. Compared with the sham group, SAP significantly reduced IκB level, which was rescued by fentanyl.

Conclusions

Fentanyl effectively alleviates SAP-induced pancreas and heart injuries through regulating the nuclear factor-κB (NF-κB) signaling pathway.

A Rare Cause of Recurrent Acute Pancreatitis in a Child: Isovaleric Acidemia with Novel Mutation

Recurrent acute pancreatic attacks is a rare clinical condition (2-5% of all acute pancreatis) in children and is mainly idiopathic in most cases. Sometimes it may be associated with congenital anomalies, metabolic diseases or hereditary conditions. Isovaleric acidemia (IVA) is a rare autosomal recessive amino acid metabolism disorder associated with isovaleryl coenzyme A dehydrogenase deficiency presenting the clinical findings such metabolic acidosis with increased anion gap, hyperammonemia, ketonemia, hypoglycemia, "the odor of sweaty feet," abdominal pain, vomiting, feeding intolerance, shock and coma. Recurrent acute pancreatitis associated with IVA have been rarely reported. Herein; we report a child who admitted with recurrent acute pancreatic attacks and had the final diagnosis of IVA. Mutation analysis revealed a novel homozygous mutation of (p.E117K [c.349G>A]) in the IVA gene. Organic acidemias must kept in mind in the differential diagnosis of recurrent acute pancreatic attacks in children.

Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 2

OBJECTIVE

To describe a number of conditions and therapies associated with multiple organ dysfunction syndrome presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Multiple Organ Dysfunction Workshop (March 26-27, 2015). In addition, the relationship between burn injuries and multiple organ dysfunction syndrome is also included although it was not discussed at the workshop.

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions and therapies were presented, discussed, and debated with a focus on identifying knowledge gaps and the research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by relevant literature.

CONCLUSIONS

Sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndrome both in children and adults. However, many other pathophysiologic processes may result in multiple organ dysfunction syndrome. In this article, we discuss conditions such as liver failure and pancreatitis, pathophysiologic processes such as ischemia and hypoxia, and injuries such as trauma and burns. Additionally, therapeutic interventions such as medications, blood transfusions, transplantation may also precipitate and contribute to multiple organ dysfunction syndrome. The purpose of this article is to describe the association of multiple organ dysfunction syndrome with a variety of conditions and therapies in an attempt to identify similarities, differences, and opportunities for therapeutic intervention.

Pancreatitis in Children

Pancreatic disease in children has a wide clinical spectrum and may present as Acute pancreatitis (AP), Acute recurrent pancreatitis (ARP), Chronic pancreatitis (CP) and Pancreatic disease without pancreatitis. This article highlights the etiopathogenesis and management of pancreatitis in children along with clinical data from five tertiary care hospitals in south India [Chennai (3), Cochin and Pune].

Genetic Analysis of Japanese Children With Acute Recurrent and Chronic Pancreatitis

OBJECTIVES

Causes of acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP) are sometimes difficult to determine in children. In such patients, genetic analysis may prove helpful. The present study analyzed mutations of cationic trypsinogen (PRSS1), serine protease inhibitor Kazal type 1 (SPINK1), chymotrypsin C (CTRC), and carboxypeptidase A1 (CPA1) and investigated the clinical features of children with these mutations.

METHODS

Genetic analyses of mutations in these 4 genes were conducted in 128 patients with ARP or CP. Characteristics of the patients showing mutations were investigated using medical records.

RESULTS

Fifty of the 128 (39.1%) subjects had at least 1 mutation (median age at onset, 7.6 years). Abdominal pain was the presenting symptom of pancreatitis in 48 of the 50 patients (96%). Fifteen of those 50 patients (30.0%) had a family history of pancreatitis. Gene mutations were present in PRSS1 in 26 patients, SPINK1 in 23, CTRC in 3, and CPA1 in 5. In the 31 patients with mutations in SPINK1, CTRC, or CPA1, 16 (51.6%) had homozygous or heterozygous mutations with other mutations. Three patients underwent surgery and another 4 patients underwent endoscopy to manage ARP or CP. Although 3 of the 7 patients complained of mild abdominal pain, none of those 7 patients experienced any obvious episode of ARP after treatment.

CONCLUSIONS

In pediatric patients with idiopathic ARP and CP, genetic analysis is useful for identifying the cause of pancreatitis. Early endoscopic or surgical treatment prevents ARP by extending the interval between episodes of pancreatitis in this population.

Sporadic Burkitt Lymphoma Presenting as Acute Pancreatitis, Concurrent Sinusitis, and Enlarged Adenoids

Pancreatitis and sinusitis as presentations of Burkitt lymphoma are uncommon and rarely described in children. We describe here the case of a child who presented with symptoms suggestive of sinusitis unresponsive to antibiotics, with subsequent development of abdominal symptoms due to pancreatitis. He was eventually diagnosed with Burkitt lymphoma.

Prospective evaluation of the cause of acute pancreatitis, with special attention to medicines

AIM: To investigate the cause of acute pancreatitis (AP) by conducting a thorough investigation of drugs and their possible etiological role.

METHODS: We investigated the cause of AP in a large retrospective cohort of 613 adult patients admitted with AP at the Akershus University Hospital, Norway, from 2000 until 2009, who were evaluated with standard ward investigations. This group was compared with a prospectively evaluated group (n = 57) admitted from January 2010 until September 2010 who investigated more extensively using medical history and radiological assessment.

RESULTS: The groups were comparable with regards to gender, age, comorbidity and severity. The most common etiology was bile stones and alcohol, occurring in 60% in both groups. The prospective group was examined more thoroughly with regards to the use of alcohol and medicines. An increased number of radiological investigations during hospital stay and at follow-up were also performed. A more extensive use of radiological evaluation did not increase the detection frequency of bile stones. In the prospective group, more than half of the patients had two or more possible causes of pancreatitis, being mostly a combination of bile stones and drugs. No possible cause was found in only 3.5% of these patients, compared with 29.7% in the retrospective group.

CONCLUSION: A detailed medical history and extensive radiological evaluation may determine a possible etiology in almost all cases of AP. Many patients have several possible risk factors, and uncertainty remains in establishing the definitive etiology.

Acute lobar nephritis in children: Not so easy to recognize and manage

Acute lobar nephritis (ALN) is a localized non-liquefactive inflammatory renal bacterial infection, which typically involves one or more lobes. ALN is considered to be a midpoint in the spectrum of upper urinary tract infection, a spectrum ranging from uncomplicated pyelonephritis to intrarenal abscess. This condition may be difficult to recognize due to the lack of specific symptoms and laboratory findings. Therefore the disease is probably underdiagnosed. Computed tomography scanning represents the diagnostic gold standard for ALN, but magnetic resonance imagine could be considered in order to limit irradiation. The diagnosis is relevant since initial intravenous antibiotic therapy and overall length of treatment should not be shorter than 3 wk. We review the literature and analyze the ALN clinical presentation starting from four cases with the aim to give to the clinicians the elements to suspect and recognize the ALN in children.