Pediatric emergency medicine trisk 2070 2070
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sign. Similarly, a bluish discoloration around the umbilicus (Cullen sign) or
flanks (Grey Turner sign) is rare in children but portends a poor prognosis and
suggests a diagnosis of hemorrhagic pancreatitis. Signs of overt hemodynamic
instability are rarely evident at initial presentation. It is particularly important
to evaluate patients for clinical signs of hypocalcemia (Trousseau and
Chvostek signs). Jaundice may suggest distal biliary obstruction.
Diagnostic criteria have recently been updated and require two out of the
three following criteria: (1) abdominal pain compatible with acute
pancreatitis, (2) serum amylase and/or lipase three times greater than the
upper limits of normal, and (3) imaging consistent with acute pancreatitis.
While lipase is thought to be more sensitive and specific, both serum amylase
and lipase can be used in the diagnosis of acute pancreatitis. Serum lipase
levels typically begin to rise within 6 hours of symptom onset and peak
around 24 to 30 hours. The lipase level remains elevated longer than amylase
and may remain elevated for more than 1 week.
Other causes for elevated serum amylase and lipase levels include liver
failure, trauma or hepatitis, renal failure, intestinal inflammation such as celiac
or inflammatory bowel disease, intestinal obstruction or infarction, penetrating
or perforated ulcer, pneumonia, acute biliary tract disease, salpingitis, salivary
adenitis, diabetic ketoacidosis, and benign macroamylase or macrolipase.
Ultrasound should be considered first line imaging in cases of pancreatitis.
While it may not be necessary for diagnosis in patients with a clear
presentation and elevated laboratory findings, it can be useful in cases where
the diagnosis is less clear. It is also useful for the evaluation of complications
(necrosis or pseudocyst) or to evaluate for causative etiologies such as
gallstones. Abdominal CT scan and MRI/MRCP should be reserved for more
complicated cases. Endoscopic retrograde cholangiopancreatography (ERCP)
is most often used when pancreatitis is caused by biliary obstruction. It may
also be useful in evaluating for the presence and severity of pancreatitis
complications.
Management
Medical management of acute pancreatitis in the ED consists mostly of IV
fluid administration and pain control. Aggressive fluid management has been
associated with improved outcomes in children. The progression of
pancreatitis from mild to severe disease is thought to be associated with poor
local pancreatic circulation. So early fluid administration not only corrects
