Pancreatitis, by Dr. Amit Grover.
Today, I will review a case about acute pancreatitis.
Grover is a five-year-old boy admitted with abdominal pain
from an outside hospital earlier today.
An etiology for his abdominal pain
has not yet been identified.
You are the GI resident on call overnight,
and you receive a page from the nurse
that Grover is having persistent pain and emesis.
She also noticed that his heart rate seems to be elevated.
As you hear this, you should be thinking of your differential
diagnosis.
While the differential of abdominal pain
is broad, in the context of pain, emesis, and tachycardia,
you should be thinking about sepsis, hypovolemic shock,
acute pancreatitis, and a surgical abdomen.
Of note, acute pancreatitis often presents acutely,
but you can also have a gradual and variable presentation.
Not all children will have typical epigastric pain
with emesis.
Some might just have emesis, or others might have solely
a fever with irritability.
The most challenging patients are those who are nonverbal
and cannot convey pain.
For this reason, acute pancreatitis
should be on the differential for any child
with abdominal pain, emesis, persistent irritability,
or even feeding intolerance.
On the phone, you should ask the nurse
for the following, vital signs, heart rate, blood pressure,
respiratory rate, and temperature.
If febrile, then you should have a heightened concern
for sepsis.
If they're in respiratory distress,
you should also think about an effusion.
Tachycardia should make you consider pain, dehydration,
or even anemia from blood loss.
Is the patient making urine?
Are they toxic in appearance?
Once you arrive in the room, always remember your ABCs.
After this, ensure that the patient is on a monitor
and has IV access.
Ensure oxygen is hooked up.
Personnel in the room may initially just
be you and the bedside nurse.
But with a glance at the monitor and the patient,
you can assess if you'll need extra hands, like the charge
nurse or even a clinical assistant.
On physical examination, let's focus by systems.
On general appearance, do they look ill?
Do they look toxic?
What is their sign of hydration based
on their mucous membranes?
From a neurologic perspective, are they in severe pain?
Is their pain controlled?
Are they responsive?
Do they have an altered mental status?
In a pulmonary exam, is the patient tachypneic?
Could they have an effusion?
Do they have diminished air entry
or increased work of breathing?
On cardiovascular exam, are they tachycardiac?
On the abdominal exam, does the patient
have distension, edema, or bruising?
A Grey Turner sign is often a late sign of pancreatitis.
If there is family in the room, some
of the information you want to gather related
to a possible diagnosis of acute pancreatitis
includes finding out if there is any possible trigger
for the episode.
For example, are any new medications,
such as seizure medications, started?
Did they have any history of trauma
or intercurrent viral infections,
or even toxic exposures?
Knowing whether the patient has had pancreatitis in the past
or if there's a family history for pancreatic or even
liver disease, such as cholelithiasis, will be useful.
It's important to ask the family if the patient recently
has had any procedures.
Specifically, if this is a post ERCP patient,
you'll want to ask what was done during the procedure.
Did they have a sphincterotomy, was there any ductal dilation?
Was a stent placed?
You can also ask if antibiotic prophylaxis was given.
It's important to understand the onset of pain and symptoms,
and whether the patient is able to maintain hydration,
as dehydration secondary to third spacing
can happen very rapidly and lead to hypovolemic shock quickly.
Let's take a quick minute to discuss some of the most
common causes of pancreatitis.
More commonly, the adult experience
will report that either gallstones or alcohol
are the main causes.
Pediatrics is different however.
While gallstones or biliary disease are a common cause,
we also have to think about other etiologies, which
include infectious etiologies such as viral infections,
bacterial infections, or even parasitic infections.
Metabolic diseases, such as hypercalcemia
or hypertriglyceridemia.
Pancreatitis can be associated with systemic diseases
such as cystic fibrosis, inflammatory bowel
disease, alpha-1 antitrypsin deficiency, celiac disease,
HUS, HSP, Kawasaki's disease just to name a few.
Pancreatitis can be seen in the setting of sepsis or multiorgan
failure, trauma or seat belt or handlebar injuries.
Or post procedures, such as an ERCP
can also lead to pancreatitis.
Congenital causes include an annular pancreas, a pancreas
divism, or choledochal cysts.
Some patients may have a genetic mutation which predisposes them
to pancreatitis.
Finally, medications are toxic exposures.
Point of clarification.
Medication induced pancreatitis is not
well studied in children.
There are, however, certain classes or specific medications
that are more likely to cause pancreatitis in children.
Antiepileptic medications have been
associated with an increased risk of developing
acute pancreatitis.
Other specific types of medications
include the immune modulator 6-MP or the ASA derivatives.
Pediatric patients being treated for malignancy
who receive asparaginase as part of their treatment regimen
are also at increased risk of developing pancreatitis.
Once you've evaluated the patient
and determined that they are stable for the moment,
you should consider ordering the following labs and imaging
studies.
If the patient is having stool output,
you can send it for guaiac testing.
If positive, this may suggest occult bleeding, which
can be seen in the setting of trauma,
intestinal inflammation, which can cause pancreatitis,
or bleeding after a pancreatic therapeutic procedure,
such as a sphincterotomy.
Getting a CBC will allow you to assess
for anemia, leukocytosis, or neutropenia, which is
important in oncology patients.
A chemistry panel will give you a sense of their hydration
status or whether or not they're acidotic.
It can also tell you if they're hypo or hyperglycemic.
LFTs are important.
These can be trended to see if they're worsening
or if they have any evidence of cholestasis.
A CRP and ESR are often elevated in acute pancreatitis
and are most useful if you trend them.
This will give you a sense if the patient is
getting worse or better.
A lactate can be sent if a patient has a rigid abdomen
or you have a concern for peritonitis or ischemia.
The lipase and amylase are helpful if you haven't already
made a diagnosis of pancreatitis.
Blood cultures are important if the patient is febrile,
and could be concerning if the patient has
had biliary manipulation.
Could they have worsening cholangitis?
Could this be sepsis?
Is this an oncology patient who's had PEG asparaginase?
Finally, a urine analysis can allow
you to have a specific gravity, which gives you
a sense of their hemoconcentration
or intravascular volume.
You may also consider ordering imaging.
Ultrasound offers the benefit of avoiding
ionizing radiation, which is often seen with CT scans.
An ultrasound will tell you if there's
hypo enhancement, suggestive of acute inflammation,
or if there's an absent blood flow of the splenic vein
thrombosis or even a portal vein thrombosis.
Ultrasound imaging is also the optimal study
for the evaluation of gallstones or cholelithiasis
when thinking about etiologies.
It can also demonstrate the presence of fluid collection,
such as a pancreatic pseudocyst or localized collections known
as walled-off necrosis.
Newer modalities, such as contrast enhanced ultrasound,
provide information on the perfusion
of the microcirculation, but not all centers
are able to offer this.
CT scans can give you a sense of perfusion.
It should be emphasized, however,
that the utility of a CT scan is very minimal early on
in the course, and the yield for identifying necrosis
is highest after 72 hours.
Pediatric patients should not routinely
receive a CT scan to diagnose acute pancreatitis,
unless there is a concern for abdominal trauma.
MRCP can also provide information
on the ductal anatomy, strictures, or pancreatic duct
stones.
This is important in your patient with a known history
of chronic pancreatitis.
This is also useful most often after the acute episode
has subsided.
And it also offers the benefit of limiting radiation exposure.
If your initial evaluation is consistent
with acute pancreatitis, or the patient
held a diagnosis of pancreatitis and appears to be worsening,
it is important to obtain IV access immediately
and aggressively resuscitate with IV fluids.
Typically, a normal saline bolus should
be given first, followed by crystalloid IV fluids,
such as D5NS or LR at 1.5 to 2 times maintenance.
Maintaining intravascular volume is
essential in perfusion of the microcirculation
of the pancreas.
In addition, given their inflamed state,
you must remember that patients are
at risk for third spacing and spilling
fluid into the abdomen, lungs, and extravascular spaces
quickly.
If patients are fluid sensitive, ensuring
optimal fluid resuscitation remains a priority.
However, closer monitoring of vital signs
for ensuing serous physiology and urine output is advised.
If the patient is febrile, unless a known source
of infection or bacteremia is confirmed,
there is no indication to cover prophylactically
with antibiotics.
Patients with acute pancreatitis often
manifest as either mild or severe phenotypes.
The majority remain mild and often show
improvement after fluid resuscitation and analgesia.
Initiation of enteral diet early on and advancement of diet
is important.
Serial laboratory studies such as repeat lipase and amylase
are not often as relevant, as the height of a lipase
or amylase does not have a good predictive value in terms
of severity.
Unfortunately, there are no good pediatric predictors
of severe disease currently.
These patients often have a worsening
and protracted course, where they demonstrate
persistence of SIRS physiology.
They often need a higher level of care or observation
in an intensive care unit.
If you notice that your patient has any of the following signs,
these should be red flags to you that you may need
to activate an ICU evaluation.
Diminished urine output or more concentrated
urine, such as an increasing specific gravity.
Severe pain that is not controlled.
Any evidence of hemodynamic instability.
These patients may need more aggressive fluid resuscitation
and eventually vasopressor support.
If they have an altered mental status or worsening acidosis.
If the patient has a distended abdomen,
diminished femoral pulses, which increase concern
for abdominal compartment syndrome,
which may also necessitate a surgical evaluation.
If a patient has severe pancreatitis,
it is important to involve your gastroenterology colleagues
early on.
They can often provide guidance on optimal fluid resuscitation
and initiation of enteral feeding.
While no data exists in pediatrics,
there is an abundance of literature
to support the early introduction of enteral feeding
in the setting of severe acute pancreatitis.
Patients should not routinely be initiated on TPN
unless discussed with a pediatric gastroenterologist.
I hope this has provided you with a good understanding
of pancreatitis in the pediatric patient.
Thank you for watching.
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