Pancreatitis

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Basics

Description

  • Inflammation within the pancreas characterized by three phases: (i) early trypsin activation within acinar cells; followed by (ii) surrounding intrapancreatic inflammation; and finally, (iii) extrapancreatic inflammation with systemic inflammatory responses
  • Classified into acute and chronic
    • Acute pancreatitis (AP)
      • Variable presentation; most often characterized by acute onset of abdominal pain, nausea, and vomiting with elevation of pancreatic enzymes
      • Nonverbal children may present with irritability; infants may present with lethargy and fever.
      • Often self-limited, with reversible changes but can progress if not appropriately managed
      • Severe AP is rare in children; however, a high suspicion should always be maintained, as severe disease can progress rapidly and result in significant morbidity and mortality.
    • Chronic pancreatitis (CP)
      • Characterized by irreversible morphologic changes and fibrotic replacement of the pancreatic parenchyma
      • Clinically characterized by recurrent abdominal pain or evidence of exocrine and/or endocrine insufficiency
      • Often the result of a persistent and continued pancreatic inflammation secondary to acute attacks

Etiology

  • Biliary tract disease
    • Gallstones
  • Medications
    • L-asparaginase, azathioprine/6-MP, mesalamine, sulfonamides, thiazides, furosemide, tetracyclines, valproic acid, corticosteroids, estrogens, procainamide, ethacrynic acid, and others
  • Toxins
    • Alcohol, organophosphates, scorpion poison, snake poison
  • Trauma
    • Bicycle handle injuries
    • Motor vehicle collisions
    • Child abuse
    • Postoperative
      • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Systemic disease
    • Shock/hypoxemia/sepsis
    • Inflammatory bowel disease (IBD)
    • Cystic fibrosis
  • Idiopathic
  • Less common
    • Infections
      • Bacterial: typhoid, mycoplasma
      • Viral: measles, mumps, Epstein-Barr virus, coxsackie B, rubella, influenza, echovirus, hepatitis A and B
      • Parasites: Ascaris lumbricoides, Echinococcus granulosus, Cryptosporidium parvum, Plasmodium falciparum
    • Metabolic diseases:
      • Hyperlipidemia
      • Hypercalcemia
      • Diabetic ketoacidosis
      • Uremia
      • Inborn errors of metabolism
    • Systemic diseases:
      • Hemolytic uremic syndrome (HUS)
      • Celiac disease
      • Diabetes mellitus
      • Vasculitis: systemic lupus erythematosus (SLE), Henoch-Schönlein purpura, Kawasaki disease
  • Rare causes:
    • Autoimmune pancreatitis: rare condition divided into two subtypes
      • Type I often grouped with IgG4-related disease and systemic manifestations.
      • Type II does not have IgG4 association, however, is more common in younger patients and associated with IBD.
    • Congenital anomalies:
      • Pancreatic divisum
      • Annular pancreas
      • Anomalous pancreaticobiliary junction
      • Biliary tract malformations
      • Duplication cyst of the duodenum/gastropancreatic/common bile duct (CBD)
    • Gene mutations
      • PRSS1: trypsinogen
      • SPINK1: serine protease inhibitor of Kazal type 1
      • CFTR: cystic fibrosis transmembrane regulator
      • CTRC: chymotrypsin C
      • CASR: calcium-sensing receptor

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