Acute Pancreatitis

Ultrasound is the initial imaging modality for suspected uncomplicated acute pancreatitis in children because it is radiation-free and gives a reasonably good look at the pancreas.

Ultrasound is limited in the setting of suspected complications of pancreatitis; CT is the image of choice for complicated cases to better visualize necrosis, fluid collections, hemorrhage, or masses.

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

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

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

MRCP is not the most helpful imaging modality during an acute pancreatitis attack because edema obscures ductal anatomy; it is better reserved for workup of biliary and pancreatic ductal issues after resolution.

There is no data identifying a superior pain medication for acute pancreatitis; even adult studies have not identified optimal management.

Opioids should not be avoided in acute pancreatitis; when used appropriately, they can help advance feeds, improve outcomes, and facilitate earlier discharge.

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

A 2012 meta-analysis comparing TPN versus enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, reduced surgical intervention rate, lower mortality, and fewer infections.

Studies comparing NG feeds versus NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality were very similar, even in severe acute pancreatitis.

The Ekerwal 2007 study randomized 60 adult patients to eat on admission versus NPO and found that early feeding did not increase abdominal pain and decreased length of stay by 2 days.

In a Cincinnati Children's study of 38 admissions for mild pancreatitis, early nutrition was safe and feasible, and patients who received feeds had similar pain scores to those kept NPO.

Pilot analysis showed patients with the lowest pain scores were those who ate the most fat; fat intake did not increase length of stay.

Aggressive IV fluid resuscitation (more than one-third of 72-hour fluid volume given in the first day) is associated with reduced mortality and reduced incidence of SIRS and organ failure at 72 hours.

In studies of aggressive resuscitation, the late resuscitation group received more total fluid than the early resuscitation group, suggesting a critical 24-hour window for intervention.

A 2011 study of 40 patients using goal-directed management (resuscitating to urine output of 3 mL/kg/hour) showed early resuscitation with lactated Ringer's reduced inflammation markers (CRP) compared to normal saline.

In a Cincinnati Children's study of 201 patients, those kept NPO with low IV fluids had 35% rate of developing severe pancreatitis, versus 4.2% in those who ate early and received aggressive resuscitation.

The pancreas can be difficult to visualize on ultrasound in larger patients, in patients who are not NPO (stomach full of gas), or when there is ileus from inflammation; bowel gas affects ultrasound wave penetration.

For CT imaging of acute pancreatitis, a single portal venous phase is sufficient; multi-phase imaging is not needed in pediatric patients as the goal is to identify complications (venous thrombosis, necrosis, fluid collections), not masses.

Oral contrast is helpful in CT of pancreatitis to separate fluid-filled bowel loops from pancreatic fluid collections, but a sick patient who cannot tolerate oral contrast can still have an informative CT without it.

On contrast-enhanced CT, absent enhancement in pancreatic tissue is highly concerning for necrosis.

Ranson's criteria have not proven sensitive and specific for predicting severity in pediatric pancreatitis when validated in further studies, despite initial promise in a 2002 Midwest study.

A Cincinnati Children's prognostic tool using white blood cell count, albumin value, and lipase on admission can predict severity in almost 70% of pediatric pancreatitis patients.

Antibiotics should not be used routinely in mild acute pancreatitis or in severe pancreatitis unless there is infected necrosis.

When antibiotics are indicated for infected pancreatic necrosis, imipenem or 3rd generation cephalosporins are good initial choices.

In MRI of the pancreas after acute attacks have resolved, a prominent pancreatic duct (visible as a white stripe) and some atrophy/irregularity of contour may be seen, but these findings alone are not diagnostic of chronic pancreatitis.

The INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month.

Workup for acute recurrent pancreatitis includes inflammatory causes (IBD, celiac), systemic illnesses, mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing for PRSS1, SPINK1, CFTR, and CTRC.

Sticking needles or drains into the pancreas risks introducing infection into sterile necrosis; intervention should be avoided unless there is true significant clinical deterioration.

In adult literature, there is growing evidence for endoscopic necrosectomy via EUS (transmural approach through stomach into necrotic cavity) showing good outcomes, but pediatric experience is extremely limited.

Evidence for secretin-enhanced MRCP in pediatric pancreatitis is limited; even adult literature shows iffy data on added value, though it may improve visualization of ductal anomalies in some cases.

In a prospective acute pancreatitis registry at Cincinnati Children's (nearly 3 years old), increased weight percentile-for-age (not BMI) during the first attack predicts recurrence.

Higher BMI may predict severe pancreatitis course in adults and children based on studies outside the US, though this has not yet been proven in the Cincinnati US population (sample size 85 patients).