Acute Pancreatitis (<18 years old) - Curbside
Acute Pancreatitis (<18 years old)
Editors: Yoyo Zhang, MD, Zachary Sellers, MD, PhD, Dan Imler, MD
Inclusion Criteria  (All criteria are present)
  • Abdominal pain concerning for pancreatitis
Exclusion Criteria
  • Complex history of abdominal surgery

Evaluate for other etiologies of acute abdominal pain.

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Evidence
Total Notes: 13
Evidence

1 Pancreatitis



References:
  1. Acute pancreatitis in children and adolescents.
    Suzuki M, Sai JK, Shimizu T,
    World J Gastrointest Pathophysiol 2014 Nov;5(4):416-26.

2 Diagnosis

According to the revised Atlanta criteria and INSPPIRE definitions, a diagnosis of acute pancreatitis (AP) is achieved by meeting 2 of the following 3 elements: clinical symptoms, including abdominal pain, nausea, vomiting, or back pain; serum levels of pancreatic amylase and/or lipase 3 times the upper limit of normal; radiographic evidence of AP including pancreatic edema on ultrasound (US) or MRI or computed tomography (CT).

A detailed history to inquire about possible etiologies of AP should be obtained to allow appropriate management. Information obtained should include trauma history, gallstones, medications, viral infections, and other possible etiologies of AP.



References:
  1. Definitions of pediatric pancreatitis and survey of present clinical practices.
    Morinville VD, Husain SZ, Bai H, Barth B, Alhosh R, Durie PR, Freedman SD, Himes R, Lowe ME, Pohl J, Werlin S, Wilschanski M, Uc A, Uc A,
    J. Pediatr. Gastroenterol. Nutr. 2012 Sep;55(3):261-5.
  2. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus.
    Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS, Vege SS,
    Gut 2013 Jan;62(1):102-11.
  3. Practice guidelines in acute pancreatitis.
    Banks PA, Freeman ML, Freeman ML,
    Am. J. Gastroenterol. 2006 Oct;101(10):2379-400.

3 Pediatric SIRS Criteria / Organ Dysfunction

Identification of SIRS / Organ dysfunction is key to proper management of the pediatric patient with acute pancreatitis. These patients are at high risk for sepsis and early intervention is often nessessary.



References:
  1. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.
    Goldstein B, Giroir B, Randolph A, Randolph A,
    Pediatr Crit Care Med 2005 Jan;6(1):2-8.
  2. 2012 revision of the Atlanta classification of acute pancreatitis.
    Sarr MG,
    Pol. Arch. Med. Wewn. 2013;123(3):118-24.

4 Goal-Directed Fluid Resuscitation

Overall Goal:

  • Early goal-directed fluid resuscitation without fluid overloading patients
  • Frequent checkpoints prompt repeat physical exams and vital signs checks, which provide key information on fluid status (as opposed to simply relying on numbers in the EMR).
  • Checkpoint 3 includes repeat labs. We anticipate that around 24-48 hrs is when the second set of labs will be drawn (assuming 1st set of labs drawn at admission). We wanted to eliminate unnecessary blood draws during the first 24 hours.


References:
  1. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis.
    Wu BU, Hwang JQ, Gardner TH, Repas K, Delee R, Yu S, Smith B, Banks PA, Conwell DL,
    Clin. Gastroenterol. Hepatol. 2011 Aug;9(8):710-717.e1.
  2. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality.
    Gardner TB, Vege SS, Chari ST, Petersen BT, Topazian MD, Clain JE, Pearson RK, Levy MJ, Sarr MG,
    Pancreatology 2009;9(6):770-6.
  3. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis.
    Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie T, Robinson S, Burchard PR, Gordon SR, Gardner TB,
    Clin. Gastroenterol. Hepatol. 2011 Aug;9(8):705-9.
  4. Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study.
    de-Madaria E, Soler-Sala G, Snchez-Pay J, Lopez-Font I, Martnez J, Gmez-Escolar L, Sempere L, Snchez-Fortn C, Prez-Mateo M,
    Am. J. Gastroenterol. 2011 Oct;106(10):1843-50.
  5. Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better?
    Eckerwall G, Olin H, Andersson B, Andersson R,
    Clin Nutr 2006 Jun;25(3):497-504.
  6. Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis?
    Brown A, Baillargeon JD, Hughes MD, Banks PA,
    Pancreatology 2002;2(2):104-7.
  7. Acute pancreatitis: bench to the bedside.
    Pandol SJ, Saluja AK, Imrie CW, Banks PA,
    Gastroenterology 2007 Mar;132(3):1127-51.
  8. Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis.
    Buxbaum JL, Quezada M, Da B, Jani N, Lane C, Mwengela D, Kelly T, Jhun P, Dhanireddy K, Laine L,
    Am. J. Gastroenterol. 2017 May;112(5):797-803.

5 Analgesia interventions

  • Pain is the primary complaint of many acute pancreatitis patients

  • Begin with scheduled tylenol with opiate for breakthrough, escalate as needed

  • Persistent or worsening pain should prompt the clinician to evaluate complications or reconsider etiology 



References:
  1. Opioids for acute pancreatitis pain.
    Basurto Ona X, Rigau Comas D, Urrtia G,
    Cochrane Database Syst Rev 2013(7):CD009179.
  2. Parenteral analgesics for pain relief in acute pancreatitis: a systematic review.
    Meng W, Yuan J, Zhang C, Bai Z, Zhou W, Yan J, Li X,
    Pancreatology;13(3):201-6.
  3. Indomethacin treatment of acute pancreatitis. A controlled double-blind trial.
    Ebbehj N, Friis J, Svendsen LB, Blow S, Madsen P,
    Scand. J. Gastroenterol. 1985 Sep;20(7):798-800.
  4. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis.
    Thompson DR,
    Am. J. Gastroenterol. 2001 Apr;96(4):1266-72.
  5. Pancreatic pain: a mini review.
    Cruciani RA, Jain S,
    Pancreatology 2008;8(3):230-5.

6 IV analgesia

In most situations, PO medications are well tolerated.  Most important is to achieve good, consistent pain control, thus IV medications may be used to do this if patient only tolerating minimal oral intake or to give medications while patient is sleeping.

NSAID should be added as long as creatinine is normal and no signs of AKI.



References:

7 Nutritional intervention

  • Strong evidence for early enteral nutrition in mild acute pancreatitis in pediatric population

  • Diet advancement should be patient-driven

  • Pain and nausea should be well-controlled to optimize patient’s ability to eat

  • Diet advance often prolongs admission—we propose making diet advancement part of nursing assessment.



References:
  1. Nutrition support in acute pancreatitis: a systematic review of the literature.
    McClave SA, Chang WK, Dhaliwal R, Heyland DK,
    JPEN J Parenter Enteral Nutr;30(2):143-56.
  2. Nutrition and acute pancreatitis: review of the literature and pediatric perspectives.
    Kumar S, Gariepy CE,
    Curr Gastroenterol Rep 2013 Aug;15(8):338.
  3. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis.
    Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW,
    Am. J. Gastroenterol. 2005 Feb;100(2):432-9.
  4. A full solid diet as the initial meal in mild acute pancreatitis is safe and result in a shorter length of hospitalization: results from a prospective, randomized, controlled, double-blind clinical trial.
    Moraes JM, Felga GE, Chebli LA, Franco MB, Gomes CA, Gaburri PD, Zanini A, Chebli JM,
    J. Clin. Gastroenterol. 2010 Aug;44(7):517-22.
  5. A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE II > or =6).
    Gupta R, Patel K, Calder PC, Yaqoob P, Primrose JN, Johnson CD,
    Pancreatology 2003;3(5):406-13.
  6. Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance.
    Petrov MS, Correia MI, Windsor JA,
    JOP 2008;9(4):440-8.
  7. Early nasogastric feeding in predicted severe acute pancreatitis: A clinical, randomized study.
    Eckerwall GE, Axelsson JB, Andersson RG,
    Ann. Surg. 2006 Dec;244(6):959-65; discussion 965-7.
  8. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes.
    Kumar A, Singh N, Prakash S, Saraya A, Joshi YK,
    J. Clin. Gastroenterol.;40(5):431-4.
  9. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis.
    Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA,
    Clin. Gastroenterol. Hepatol. 2007 Aug;5(8):946-51; quiz 886.
  10. Clinical trial: oral feeding with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis.
    Sathiaraj E, Murthy S, Mansard MJ, Rao GV, Mahukar S, Reddy DN,
    Aliment. Pharmacol. Ther. 2008 Sep;28(6):777-81.
  11. Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute Pancreatitis.
    Szabo FK, Fei L, Cruz LA, Abu-El-Haija M,
    J. Pediatr. 2015 Aug;167(2):397-402.e1.
  12. Early Enteral Nutrition in Children With Acute Pancreatitis.
    Abu-El-Haija M, Wilhelm R, Heinzman C, Siqueira BN, Zou Y, Fei L, Cole CR,
    J. Pediatr. Gastroenterol. Nutr. 2016 Mar;62(3):453-6.

8 Diagnostic Work-up of Acute Pancreatitis

Why Order Both Amylase & Lipase?

The sensitivity of the amylase test in diagnosing pancreatitis in children has ranged from 50% to 85%. Lipase was only marginally more sensitive than amylase in most studies.

An oft-cited paper by Park et al. noted a sensitivity of 77.3% for lipase, which was about 25% more sensitive than amylase in their study. The sensitivity for amylase or lipase (>3× upper limit of normal) combined was only 4% higher than lipase alone.

However, this does not mean that the amylase test is dispensable. There are numerous case reports showing elevations in only the amylase at time of diagnosis. It is important to note that numerous illnesses can cause elevation of one or both of these enzymes.

Amylase activity rises quickly within the first 12 hours after the onset of symptoms and returns to normal within three to five days. Lipase activity remains increased for longer (up to 8 to 14 days). Getting both tests helps with understanding timing of onset or resolution of disease.



References:
  1. Biochemical markers of acute pancreatitis.
    Matull WR, Pereira SP, O'Donohue JW,
    J. Clin. Pathol. 2006 Apr;59(4):340-4.
  2. What have we learned about acute pancreatitis in children?
    Bai HX, Lowe ME, Husain SZ,
    J. Pediatr. Gastroenterol. Nutr. 2011 Mar;52(3):262-70.
  3. A comparison of presentation and management trends in acute pancreatitis between infants/toddlers and older children.
    Park AJ, Latif SU, Ahmad MU, Bultron G, Orabi AI, Bhandari V, Husain SZ,
    J. Pediatr. Gastroenterol. Nutr. 2010 Aug;51(2):167-70.

9 Ultrasound



References:
  1. Pancreatitis and the role of US, MRCP and ERCP.
    Darge K, Anupindi S,
    Pediatr Radiol 2009 Apr;39 Suppl 2:S153-7.

10 Reasons for amylase or lipase elevations

Causes of Amylase Elevation:

Abdominal Causes:

  • Biliary tract disease
  • Intestinal obstruction/ischemia
  • Mesenteric infarction
  • Peptic ulcer
  • Appendicitis
  • Ruptured ectopic pregnancy
  • Ovarian neoplasm
  • Dissecting aortic aneurysm

Non-Abdominal Causes:

  • Salivary: trauma, infection (mumps), duct obstruction
  • Thoracic: myocardial infarcation, PE, pneumonia
  • Diabetic Ketoacidosis
  • Opiates
  • Trauma: cerebral trauma, burns
  • Renal: insufficiency (decreased clearance of amylase)
  • Macroamylasemia (amylase is bound to immunoglobulins or polysaccharides to form large molecular weight complexes)

Causes of Lipase Elevation:

  • Macrolipasemia
  • Renal insufficiency
  • Esophagitis
  • Hypertriglyceridemia


References:
  1. A critical evaluation of laboratory tests in acute pancreatitis.
    Yadav D, Agarwal N, Pitchumoni CS,
    Am. J. Gastroenterol. 2002 Jun;97(6):1309-18.
  2. Lipase in serum--the elusive enzyme: an overview.
    Tietz NW, Shuey DF,
    Clin. Chem. 1993 May;39(5):746-56.
  3. What have we learned about acute pancreatitis in children?
    Bai HX, Lowe ME, Husain SZ,
    J. Pediatr. Gastroenterol. Nutr. 2011 Mar;52(3):262-70.

11 Blank



References:

12 Fat Intake in Pediatric Acute Pancreatitis

There is no data in pediatrics that a low fat diet is beneficial in the treatment of mild acute pancreatitis (with the exception of hypertriglyceridemia-induced pancreatitis).  In a 2016 retrospective study, higher enteral fat intake did not correlate with worse pain, increased lipase, or length of stay. Further studies are required to determine if there is any role for fat restriction in pediatrics.  For now, we do not generally recommend fat restriction, unless the patient has first failed regular age-appropriate diet.

Low fat diet = 0.5 g/kg/day or <30% daily caloric intake from fat



References:
  1. Early Enteral Nutrition in Children With Acute Pancreatitis.
    Abu-El-Haija M, Wilhelm R, Heinzman C, Siqueira BN, Zou Y, Fei L, Cole CR,
    J. Pediatr. Gastroenterol. Nutr. 2016 Mar;62(3):453-6.

13 NG and NJ Feeding

NG and NJ tube feedings have been shown to be safe and equally effective in providing nutrition to those with pancreatitis, even those with severe pancreatitis.

There is no evidence to suggest a preference of using polymeric vs. elemental formulas to NG or NJ tube feedings.



References:
  1. Nasogastric nutrition is efficacious in severe acute pancreatitis: a systematic review and meta-analysis.
    Nally DM, Kelly EG, Clarke M, Ridgway P,
    Br. J. Nutr. 2014 Dec;112(11):1769-78.
  2. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis.
    Chang YS, Fu HQ, Xiao YM, Liu JC,
    Crit Care 2013 Jun;17(3):R118.
  3. Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance.
    Petrov MS, Correia MI, Windsor JA,
    JOP 2008 Jul;9(4):440-8.