International Clinical Practice Guidelines: 2018 Midyear Review

Childhood Pancreatitis

European Pancreatic Club and Hungarian Pancreatic Study Group

Acute pancreatitis (AP): The first acute episode of pediatric pancreatitis occurs before the age of 18 years. The diagnosis of AP is made by meeting at least 2 of the following 3 criteria:

1. Abdominal pain

2. Serum lipase or serum amylase level at least 3 times greater than the upper limit of normal

3. Characteristic findings of AP on imaging

Diffuse, epigastric, persistent, or minimally easing abdominal pain suggests AP in childhood.

In children, especially in infants and in toddlers, vomiting, irritability, abdominal distention may suggest AP.

Measurement of serum amylase and/or lipase among the routine laboratory tests is recommended in the presence of abdominal pain.

Etiological factors that should be considered after the diagnosis is reached are the following:

• Biliary and pancreatic abnormalities

• Medication-associated

• Underlying systemic disease

• Trauma

• Genetic predisposition

• Infection

• Metabolic disorders

• Autoimmune pancreatitis

In patients with a second episode of idiopathic AP or a first episode of idiopathic AP and a family history of AP or chronic pancreatitis (CP), full-sequence analysis of the PRSS1, CPA1, SPINK1, CTRC, and CFTR gene exons and exon-intron boundaries and testing for the CEL gene pathogenic hybrid allele is recommended in order to explore the etiologic background.

Transabdominal ultrasonography is recommended as a first-choice imaging technique in pediatric AP.

Contrast-enhanced abdominal computed tomography (CT) is recommended in children with clinical deterioration, as per adult guidelines.

If the clinical presentation of the child suggests pancreatic necrosis, contrast-enhanced abdominal CT or MRI is recommended, as per adult guidelines. The optimal timing of the scan is at least 72–96 hr after presentation with pancreatitis.

ERCP is not recommended for diagnostic purposes.

Dextrose-containing crystalloids are recommended as the initial choice for replacement fluid therapy in AP.

Due to lack of unequivocal guidelines, early aggressive fluid management (at a rate of more than 1.5–2 times the maintenance rate of IV fluids) is recommended in children in the first 24 hr.

Oral feeding can be started as soon as tolerated, even in the presence of systemic inflammation and before the amylase or lipase values have decreased.

If adequate oral feeding is not tolerated or the required calories cannot be achieved by oral feeding within 72 hr, enteral tube feeding is recommended.

Elemental and polymeric formulas are both appropriate in the management of AP.

Complete parenteral feeding is used as a second-line treatment in AP when enteral nutrition is not tolerable for the patient and additional nutrition is necessary.

Regardless of the severity of the pancreatitis or existing necrosis, routine use of prophylactic antibiotics is not recommended in AP.

In cases of systemic infectious complications, cholangitis or suspected infected pancreatic necrosis, antibiotic treatment is recommended.

In cases of severe cholangitis, ERCP should be done urgently within 24 hr. In other cases of cholangitis and/or obstruction, ERCP should be performed within 72 hr.

For uncomplicated biliary pancreatitis, cholecystectomy is recommended during the index admission if possible or, if not possible, within 30 days of the first admission for mild cholelithiasis-associated AP in children. Importantly, if cholecystectomy is not performed, the patient remains at risk of another episode of AP and complications of gallstones.

The most common medications associated with AP in children are valproic acid, mesalazine, thiopurines, and asparaginase.

Acute recurrent pancreatitis (ARP) is defined by at least 2 acute attacks in a year or more than 3 in the patient's lifetime without any evidence of CP. There must be complete resolution of pain (≥1 month pain-free interval between the diagnoses of AP, or complete normalization of serum pancreatic enzyme levels (amylase and lipase), before the subsequent episode of AP is diagnosed, along with complete resolution of pain symptoms, irrespective of a specific time interval between AP episodes. Studies suggest that children who had AP have a 10–35% chance of another attack.

Chronic pancreatitis (CP) is an irreversible inflammatory process that leads to changes in the pancreatic parenchyma and function. Documentation of characteristic histologic and morphologic alterations or decreased exocrine or endocrine pancreas function is needed to establish the diagnosis.

Reference

• Parniczky A, Abu-El-Haija M, Husain S, et al. EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis. Pancreatology. 2018 Mar;18(2):146:160. https://www.pancreatology.net/article/S1424-3903(18)30001-2/fulltext

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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: John Anello, Brian Feinberg, John Heinegg, et. al. International Clinical Practice Guidelines: 2018 Midyear Review - Medscape - Jul 10, 2018.