Pediatric Pancreatitis Etiology and Imaging Approaches

Pediatric pancreatitis Etiology and imaging approaches

M. Mearadji International Foundation for Pediatric Imaging Aid Introduction

. Pancreatitis is nowadays recognized more often in pediatric age than previously. . The childhood pancreatitis can result form a wide range of causes. . Early diagnosis and aggressive intervention are needed in children suspected of having pancreatitis. . Pancreatitis should be classified in acute and chronic type because of differences in etiology, prognosis and treatment. Clinical presentation of pancreatitis

. Abdominal pain . Epigastric pain . Radiating pain . Colicky pain . Nausea/vomiting . Greasy stools . Fever . Jaundic . Abdominal distention

Laboratory findings

. Leucocytosis. . Increased hematocrit. . Hypocalcemia (15 %). . Hyperglycemia (25 %). . Elevated serum amylase concentration. . Lipase elevated in serum and urinary.

Imaging approaches in diagnosis of pancreatitis

. Abdominal plain film, nonspecific. . Sonography (initial imaging procedure). . CT superior to sonography. . MRCP (Magnetic Resonance Cholangio- Pancreatography). . ERCP (Endoscopic Retrograde Cholangio- Pancreatography.

Conditions associated with childhood pancreatitis

Physical injuries Abdominal trauma, ERCP Multisystem disease Crohn’s disease, hemolytic uremic syndrome Metabolic disorders Hyperlipidemia, uremia Toxics Alcohol, Yellow scorpion bite Nutricinal problems Malnutricion, rapid refeeding. Pancreas disorder Cystic fibrosis, pancreas divisum Biliary tract obstruction Choledochus cyst, gallstones Vasculitis Henoch-Schönlein, periarteritis Drugs Asparaginase, Azathioprine Infections Campylobacter, Salmonella typhi Viruses Mumps, Coxacie B, Hepatitis B Miscellaneous Graft versus Host disease, hereditary Acute pancreatitis

. Is an uncommon gastrointestinal emergency with sudden inflammation of pancreas. . The severity of an acute pancreatitis can be described as mild, moderate or severe and as necrotizing pancreatitis. . The proces of acute pancreatitis is mostly self limiting in mild cases. . A severe acute pancreatitis is associated with a high rate of complication. . The course and outcome of acute pancreatitis are somewhat determined by the underlying etiology. Chronic pancreatitis

. Chronic pancreatitis is a destructive inflammatory process of the pancreas. . Ultimately chronic pancreatitis leads to total or partial decline of endo- and exocrine function of the pancreas. . Abdominal pain, digestive functional disturbance, steatorrhea and diabetes mellitus are the clinical features of chronic pancreatitis. Clinical data of 37 children with an acute (28) and chronic (9) pancreatitis

. Age: 1 – 17 years (average 9). . Sex: 24 girls and 13 boys. . Elevated serum or urinary amylase: 29.

Imaging procedures in all 37 cases of pancreatitis

Abdominal plain film 10

Sonography 35 (range 1-7 times per patient)

CT 21 (range 1-3 times per patient)

MRCP 16 (range 1-2 times per patient)

ERCP 13 (mostly as intervention) Conditions associated with acute pancreatitis in 28 cases Abdominal trauma n=10 40% Iatrogenic post ERCP n=2 7% Metabolic n=6 21% Drugs n=3 9% Gall stones n=3 9% Choledochal cyst n=1 3% Pancreatis divisum n=1 3% Gastroenteritis n=1 3% Eosinophylic pancreatitis n=1 3% 7 year old boy with a pancreatic rupture caused by a bicycle accident. Pancreas rupture in a 11 year old boy caused by blunt abdominal trauma. 8 month old boy with an iatrogenic pancreatitis following ERCP. 17 year old boy with pyruvate kinase deficiency complicated with gall stone and acute pancreatitis. 12 year old girl with a metabolic disorder as hypertriglyceridemia causing pancreatitis. 15 year old girl with acute lymphatic leukemia. Pancreatitis and diabetes following Asperginase therapy. 5 year old boy treated for congenital diafragmatic hernia. Gall stone complicated with pancreatitis following parenteral feeding Conditions associated with chronic pancreatitis in 9 cases

Hereditary n=5 Idiopathic n=2 Pancreatis divisum n=1 Metabolic n=1 11 year old girl with hereditary pancreatitis. Homozygote mutation SPINKI gen 7 year old girl with hereditary recurrent pancreatitis. 22q11s gen mutation. 13 year old girl with chronic pancreatitis (pancreas divisum). 6 year old girl with recurrent pancreatitis (pancreas divisum). Pseudocyst in 37 cases of pancreatitis

Pseudocyst

Acute pancreatitis n=10 (36%) (n=28) Traumatic (n=10) n=4 (40%) Untraumatic (n=18) n=6 ( 33%) Chronic pancreatitis n=4 (44%) (n=9) 14 year old boy with a gigantic idiopathic pancreas cyst. 7 year old girl with traumatic acute pancreatitis with a gigantic pancreatic cyst. 14 year old girl with lymphoblastic non-Hodkin lymphoma. Acute pancreatitis following Asperginase therapy with a gigantic pancreatic cyst. Cystic changes and calcification of the pancreas in a15 year old boy with chronic pancreatitis by adipositas. 12 year old girl with chronic pancreatitis with a small pancreatic cyst caused by a calculus in the pancreatic duct. 2 illustrative cases of neoblastic tumor of pancreas which should be considered in the differential diagnostic of pancreatitis.

A. Carcinoid of pancreas duct with obstruction of the duct.

B. Solid pseudo papillary tumor of the pancreatic tail. Conclusion

. There are around 80 etiological conditions associated with childhood pancreatitis. . Blunt trauma is the most common cause of acute pancreatitis. . In several patients, especially in chronic pancreatitis, the etiological cause remains unknown. . Pseudocyst of pancreas develops most frequently from traumatic pancreatis or following chronic pancreatitis.

Conclusion

. Sonography is the first modality of choice for evaluation the bile ducts and pancreas. . CT is the best modality for pancreatic pathology. . MRCP should be used for imaging of the bile ducts and pancreatic duct. . ERCP is nowadays indicated as a therapeutic interventional procedure.