Acute Pancreatitis

Ultrasound is the initial imaging modality for suspected uncomplicated acute pancreatitis; it is radiation-free and gives a reasonably good look at the pancreas, but is limited for evaluating complications.

Amylase rises and normalizes much quicker than lipase; in a patient presenting 2 days after symptom onset, amylase may not be the best indicator.

Lipase half-life is about 7 days and is more specific for pancreatic/intestinal pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary issues.

The most helpful use of ultrasound in acute pancreatitis is looking for a biliary component (CBD dilation suggesting early ERCP need, or gallstones changing management), not documenting pancreatitis or looking for complications.

CT is the imaging test of choice when complicated pancreatitis is suspected; it best visualizes necrosis, fluid collections, hemorrhage, and masses.

MRCP is useful for workup of biliary and pancreatic ductal issues but is not the first imaging modality in acute pancreatitis; edema during acute attack obscures ductal anatomy.

There is no data on optimal pain medication in acute pancreatitis; even adult studies have not identified a superior medication.

Opioids used in the right patient and setting in acute pancreatitis can allow earlier feeding, improve outcomes, and enable earlier discharge; providers should not be shy about using them.

Early enteral nutrition (within 24–72 hours) in acute pancreatitis is associated with more favorable outcomes: maintains gut barrier function, inhibits bacterial translocation, lowers incidence of systemic inflammatory response, and avoids severe complications.

Cincinnati Children's replicated the early feeding approach in 38 pediatric admissions with mild pancreatitis (published late 2015); early nutrition was safe, feasible, and not associated with worse pain outcomes.

Pilot analysis showed patients who ate the most fat had the lowest pain scores; fat intake did not increase length of stay. Patients likely self-regulate and eat more when ready.

In the late resuscitation group, patients received more total fluid than the early resuscitation group, but outcomes were worse, indicating a critical 24-hour window for intervention.

Cincinnati Children's study of 201 patients showed 35% of NPO + low IV fluids group developed severe pancreatitis vs. 4.2% in early PO + aggressive resuscitation group.

For pediatric pancreatitis CT, a portal venous phase is sufficient (no multi-phase needed); oral contrast helps separate fluid-filled bowel from pancreatic fluid collections but is not a deal-breaker if patient cannot tolerate it.

Absent enhancement on contrast-enhanced CT is highly concerning for pancreatic necrosis.

Ranson's criteria applied to pediatric pancreatitis (studied since 2002, including Midwest/University of Cincinnati studies) initially showed promise but did not prove sufficiently sensitive and specific upon validation.

Cincinnati Children's study proposes using white blood cell count, albumin, and lipase on admission to predict severity in ~70% of pediatric pancreatitis patients; this tool still needs optimization.

Antibiotics should not be used in mild pancreatitis or in severe pancreatitis unless infected necrosis is suspected (e.g., fever present).

When antibiotics are indicated in pancreatitis, imipenem or 3rd-generation cephalosporins are good initial choices based on available evidence.

ARP workup includes inflammatory causes (IBD, celiac), systemic/mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing (PRSS1, SPINK1, CFTR, CTRC).

Aspiration of pancreatic necrosis to rule out infection carries risk of introducing infection into a sterile collection; empiric antibiotics may be started if fever is present, but aspiration is rarely performed (Cincinnati has needed one necrosectomy in 10 years).

Adult evidence supports endoscopic necrosectomy via EUS-guided transmural approach with good outcomes; pediatric experience is extremely limited and Cincinnati has not performed this procedure.

Secretin-enhanced MRCP has unclear added value in pediatric pancreatitis; adult literature data is 'iffy.' In acute recurrent or chronic pancreatitis patients, ducts are often dilated enough to visualize without secretin.

Cincinnati Children's prospective acute pancreatitis registry (3 years, 85 patients) found increased weight percentile for age (not BMI) during first attack predicts recurrence; abstract submitted to World Congress.

Higher BMI predicts severe pancreatitis course in adults and some pediatric studies outside the US, but did not predict severity in Cincinnati's 85-patient sample, possibly due to wide BMI variation in both recurrence and non-recurrence groups.