Pediatric emergency medicine trisk 2066 2066
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CLINICAL PEARLS AND PITFALLS
One-third of acute pancreatitis cases will develop into severe acute
pancreatitis.
Aggressive fluid management with crystalloid fluids is associated
with improved outcomes.
Mild trauma from small pointed objects, such as sticks, handlebars,
or fence posts, may transmit injury directly to the pancreas.
Serum amylase and lipase levels may not correlate with severity of
disease.
There is no indication for empiric antibiotics unless necrosis or
infection is suspected.
Current Evidence
Pancreatitis occurs in approximately 1/10,000 children per year, and the
incidence has been increasing in recent years. It can be caused by anatomic
abnormalities, obstructive or biliary disease, infectious etiologies, trauma,
toxins, genetic or inborn errors of metabolism or systemic disease. In infants
and toddlers, pancreatitis is most commonly associated with multisystem
disease such as HUS or pulmonary disease. In older children and adolescents,
the most common cause of pancreatitis remains unknown or “idiopathic”
followed closely by trauma and structural disease. Table 91.3 lists the causes
of pancreatitis. Regardless of the initiating event, acute pancreatitis results in
the activation of the numerous pancreatic enzymes, including proteolytic
enzymes, lipase, amylase, elastase, and phospholipase A, which causes
autodigestion of the gland. The process may be focal or diffuse. Mild disease,
or acute edematous pancreatitis, is by far the most common form seen in
children, is usually self-limited, and associated with complete recovery.
Necrotic or hemorrhagic pancreatitis occurs when the autodigestive process
intensifies with increased inflammation, fat necrosis, and hemorrhagic
changes. It is associated with significant morbidity and mortality, with the
mortality rate approaching 10%. Complications from severe pancreatitis
include pseudocyst formation, necrosis, secondary bacterial infections, acute
respiratory distress syndrome, shock, multiorgan system failure, and death.
Early in the disease it is difficult to predict which patients are at risk for severe
disease and a poor prognosis. There are several well-validated scoring systems
