Pediatric pancreatitis Etiology and imaging approaches

M. Mearadji

International Foundation for Pediatric Imaging Aid

Introduction

Pancreatitis is nowadays recognized more often in pediatric age than previously.

The childhood pancreatitis can result form a wide range of causes.

Early diagnosis and aggressive intervention are needed in children suspected of having pancreatitis.

Pancreatitis should be classified in acute and chronic type because of differences in etiology, prognosis and treatment.

Clinical presentation of pancreatitis

Abdominal pain

Epigastric pain

Radiating pain

Colicky pain

Nausea/vomiting

Greasy stools

Fever

Jaundic

Abdominal distention

Laboratory findings

Leucocytosis.

Increased hematocrit.

Hypocalcemia (15 %).

Hyperglycemia (25 %).

Elevated serum amylase concentration.

Lipase elevated in serum and urinary.

Imaging approaches in diagnosis of pancreatitis

Abdominal plain film, nonspecific.

Sonography (initial imaging procedure).

CT superior to sonography.

MRCP (Magnetic Resonance Cholangio-Pancreatography).

ERCP (Endoscopic Retrograde Cholangio-Pancreatography.

Conditions associated with

childhood pancreatitis

Physical injuries Abdominal trauma, ERCP

Multisystem disease Crohn’s disease, hemolytic uremic syndrome

Metabolic disorders Hyperlipidemia, uremia

Toxics Alcohol, Yellow scorpion bite

Nutricinal problems Malnutricion, rapid refeeding.

Pancreas disorder Cystic fibrosis, pancreas divisum

Biliary tract obstruction Choledochus cyst, gallstones

Vasculitis Henoch-Schönlein, periarteritis

Drugs Asparaginase, Azathioprine

Infections Campylobacter, Salmonella typhi

Viruses Mumps, Coxacie B, Hepatitis B

Miscellaneous Graft versus Host disease, hereditary

Acute pancreatitis

Is an uncommon gastrointestinal emergency with sudden inflammation of pancreas.

The severity of an acute pancreatitis can be described as mild, moderate or severe and as necrotizing pancreatitis.

The proces of acute pancreatitis is mostly self limiting in mild cases.

A severe acute pancreatitis is associated with a high rate of complication.

The course and outcome of acute pancreatitis are somewhat determined by the underlying etiology.

Chronic pancreatitis

Chronic pancreatitis is a destructive inflammatory process of the pancreas.

Ultimately chronic pancreatitis leads to total or partial decline of endo- and exocrine function of the pancreas.

Abdominal pain, digestive functional disturbance, steatorrhea and diabetes mellitus are the clinical features of chronic pancreatitis.

Clinical data of 37 children with an acute (28) and chronic (9) pancreatitis

Age: 1 – 17 years (average 9).

Sex: 24 girls and 13 boys.

Elevated serum or urinary amylase: 29.

Imaging procedures in all 37

cases of pancreatitis

Abdominal plain film 10

Sonography 35 (range 1-7 times per patient)

CT 21 (range 1-3 times per patient)

MRCP 16 (range 1-2 times per patient)

ERCP 13 (mostly as intervention)

Conditions associated with acute

pancreatitis in 28 cases

Abdominal trauma n=10 40%

Iatrogenic post ERCP n=2 7%

Metabolic n=6 21%

Drugs n=3 9%

Gall stones n=3 9%

Choledochal cyst n=1 3%

Pancreatis divisum n=1 3%

Gastroenteritis n=1 3%

Eosinophylic pancreatitis n=1 3%

7 year old boy with a pancreatic rupture caused by a

bicycle accident.

Pancreas rupture in a 11 year old boy

caused by blunt abdominal trauma.

8 month old boy with an iatrogenic

pancreatitis following ERCP.

17 year old boy with pyruvate kinase deficiency complicated

with gall stone and acute pancreatitis.

12 year old girl with a metabolic disorder as

hypertriglyceridemia causing pancreatitis.

15 year old girl with acute lymphatic leukemia.

Pancreatitis and diabetes following Asperginase therapy.

5 year old boy treated for

congenital diafragmatic

hernia.

Gall stone complicated with

pancreatitis following

parenteral feeding

Conditions associated with

chronic pancreatitis in 9 cases

Hereditary n=5

Idiopathic n=2

Pancreatis divisum n=1

Metabolic n=1

11 year old girl with hereditary pancreatitis. Homozygote

mutation SPINKI gen

7 year old girl with hereditary recurrent pancreatitis.

22q11s gen mutation.

13 year old girl with chronic pancreatitis (pancreas divisum).

6 year old girl with recurrent pancreatitis (pancreas divisum).

Pseudocyst in 37 cases of

pancreatitis

Pseudocyst

Acute pancreatitis

(n=28)

n=10 (36%)

Traumatic (n=10)

Untraumatic (n=18)

n=4 (40%)

n=6 ( 33%)

Chronic pancreatitis

(n=9)

n=4 (44%)

14 year old boy with a gigantic idiopathic pancreas cyst.

7 year old girl with traumatic acute pancreatitis

with a gigantic pancreatic cyst.

14 year old girl with lymphoblastic non-Hodkin lymphoma.

Acute pancreatitis following Asperginase therapy with a

gigantic pancreatic cyst.

Cystic changes and calcification of the pancreas in a15

year old boy with chronic pancreatitis by adipositas.

12 year old girl with chronic pancreatitis with a small

pancreatic cyst caused by a calculus in the pancreatic duct.

A. Carcinoid of

pancreas duct

with obstruction

of the duct.

2 illustrative cases of neoblastic tumor of pancreas which should be

considered in the differential diagnostic of pancreatitis.

B. Solid pseudo

papillary tumor of

the pancreatic tail.

Conclusion

There are around 80 etiological conditions associated with childhood pancreatitis.

Blunt trauma is the most common cause of acute pancreatitis.

In several patients, especially in chronic pancreatitis, the etiological cause remains unknown.

Pseudocyst of pancreas develops most frequently from traumatic pancreatis or following chronic pancreatitis.

Conclusion

Sonography is the first modality of choice for evaluation the bile ducts and pancreas.

CT is the best modality for pancreatic pathology.

MRCP should be used for imaging of the bile ducts and pancreatic duct.

ERCP is nowadays indicated as a therapeutic interventional procedure.