Acute Pancreatitis in Infants and Toddlers Posted 03/25/2008
William T. Basco, Jr., MD, FAAP Author
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Watch a video animation Etiology and Outcome of Acute Pancreatitis in Infants and Toddlers Kandula L and Lowe ME
J Pediatr. 2008;152:106-10, 110.e1.
Summary This report outlined causes of acute pancreatitis (AP) in an age group not widely studied in the existing literature. Subjects were children younger than 3 years old admitted to the Children’s Hospital of Pittsburgh over a 10-year period from 1995 to 2004. The diagnosis of AP was made if the child had a change from usual state of health plus: at least a tripling of serum amylase (normal < 90 IU/L) or serum lipase (< 200 IU/L normal); or radiologic or surgical findings consistent with AP; or radiologic or surgical and serologic findings. The patients were not evaluated under a set protocol, so the imaging and testing completed on each patient varied according to the decisions of the responsible physicians. Patients with imaging studies and no cause identified were labeled as “idiopathic,” and patients with no cause identified but without imaging studies were labeled as “undetermined.” “Severe” cases were those where the subject had pancreatic damage caused by AP, experienced multiorgan failure, or died due to AP. The authors identified 87 subjects younger than 3 years old meeting their diagnostic criteria, and only 24% had AP as the suspected diagnosis at admission. The group was 52% male; 63% white; and had a median age of 20 months. All patients had elevated serum lipase, but only 61% had elevated amylase. The authors note that these elevated levels persisted for a median of 7 days. In patients with abdominal ultrasound, 51% had abnormal findings. Forty-seven percent of the patients who underwent computed tomography of the abdomen had abnormal results. Six patients had ERCP, and one of those was abnormal. Fever, emesis, and irritability were the most frequent findings. Abdominal distention occurred only 16% of the time. None of the patients had a family history of AP, but 58.6% of the patients did have a chronic medical condition that may have contributed to AP. Eighteen percent of the patients had seizure disorder, and 15% had short gut. One third of the patients (n = 29) had multisystem disease. Pulmonary process and hemolytic-uremic syndrome (HUS) each accounted for 7 subjects. Of note, the 7 patients with AP and HUS accounted for 22.5% of all patients admitted for HUS during the study period. Only 7% of the AP subjects had gallstones. The authors conclude that AP is associated with multisystem disease in one third of the patients, and irritability may be a more prevalent finding than abdominal pain. Large proportions of children may have neither abdominal pain nor irritability. Viewpoint There is a lot of information included in this report, but a few “take-home points” seem worth reviewing. First, consider AP when faced with patients with seizure disorder and abdominal pain or with patients with short gut who are having gastrointestinal difficulty or with HUS patients. Second, checking amylase levels alone would have missed approximately one third of the subjects. Finally, the fact that the symptoms of AP vary so much in this age group means that a higher index of suspicion would be needed to diagnose compared to older patients.
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