I. Overview
Acute pancreatitis is a chemical inflammation-based disease in which the pancreatic digestive enzymes are activated in the pancreas due to various causes, and the pancreatic self-digestion occurs. It is relatively uncommon in pediatric patients.
Etiology
Pediatric acute pancreatitis is caused by different factors than adults, the most common causes are as follows.
1, secondary to bacterial or viral infections in other parts of the body, such as acute mumps, pneumonia, bacillary dysentery, tonsillitis, etc.
2, upper gastrointestinal disorders or biliopancreatic junction site deformity, bile reflux into the pancreas, causing pancreatitis.
3, drug-induced: the application of large amounts of adrenal hormones, immunosuppressive drugs, morphine, and the application of levomentholide in the treatment of acute lymphoblastic leukemia can cause acute pancreatitis.
4, can be complicated by systemic lupus erythematosus, allergic purpura, hyperparathyroidism, Crohn’s disease, Kawasaki disease, etc..
However, there are still some cases without certain causative factors.
Clinical manifestations
Pediatric acute pancreatitis can be divided into edematous pancreatitis and hemorrhagic necrotizing pancreatitis according to pathological changes.
1. Edematous pancreatitis
The pancreatic gland is fully or locally edematous, congested and enlarged, and the drainage of pancreatic juice is obstructed, thus increasing the amylase in blood and urine. The main symptom is pain in the upper abdomen, mostly persistent, and often accompanied by nausea and vomiting. The vomit is food and gastric and duodenal secretions. In more severe cases, there is abdominal distension, and epigastric pain (left or right of the umbilicus) is the only abdominal sign, and some children have local muscle tension.
2.Hemorrhagic necrotizing pancreatitis
Systemic symptoms are critical, starting with irritability, followed by hypotension, shock, dyspnea, oliguria or anuria, severe spontaneous abdominal pain, inconsistent with the signs of abdominal pain, periumbilical and supraumbilical pressure pain and signs of peritoneal irritation. The skin of the umbilicus or waist of individual children is cyanotic, which is caused by the decomposition of subcutaneous fat by overflowing pancreatic fluid and capillary bleeding.
IV. Examination
1.Amylase measurement
The main diagnostic basis, measured by the Somogyi method, normal children are below 64 U, while acute pancreatitis is up to 500 U or more. The serum amylase value can increase after 3 hours of onset and gradually rise, peaking at 24-48 hours and then gradually decreasing. Urinary amylase also has the same change. Normal is less than 64U, but it rises slowly after the disease and decreases more slowly than serum amylase after the lesion is relieved, and it is affected by kidney function and urine concentration, so it is not as accurate as serum amylase. Other related acute abdominal diseases such as intestinal perforation, intestinal obstruction, intestinal necrosis, amylase can also be elevated, rarely more than 300-500U.
2.Serum lipase measurement
It is elevated after 24h of onset and continues to be high for a long time, and can be a diagnostic method for advanced patients. The normal value is 0.5~1U (Comfort).
3.Laparotomy
In severe cases with peritonitis, when it is difficult to differentiate from other causes of peritonitis, such as severe destruction of the pancreas, serum amylase is not increased, then the peritoneal fluid is more feasible peritoneal puncture, according to the nature of the peritoneal exudate (bloody, mixed with fat necrosis) and amylase increase, can help diagnose.
4.B ultrasound examination
It is valuable to confirm the diagnosis of edematous pancreatitis and late complication of pancreatic cysts, the former showing significant enlargement of the pancreas and the latter showing cystic masses connected with the pancreas.
5.The ratio of amylase and creatinine clearance can be measured
Urinary amylase / serum amylase × blood creatinine / urinary creatinine × 100% = normal ratio of 1% to 4%, greater than 6% suggests acute pancreatitis.
V. Diagnosis
The diagnosis can be clarified based on the child’s medical history and the above-mentioned tests.
Differential diagnosis
Should be differentiated from the following diseases.
1. Acute perforation of peptic ulcer
A more typical history of ulcer, sudden increase in abdominal pain, abdominal muscle tension, disappearance of liver turbid sounds, and free gas under the diaphragm as seen on X-ray can be distinguished.
2, cholelithiasis and acute cholecystitis
There is often a history of biliary colic, the pain is located in the right upper abdomen, often radiating to the right shoulder, Murphy’s sign is positive, blood and urine amylase is mildly elevated, ultrasound and X-ray cholangiography can make a clear diagnosis.
3.Acute intestinal obstruction
Abdominal pain is paroxysmal, abdominal distension, vomiting, hyperactive bowel sounds, with gas over water sound, no exhaust, and visible intestinal pattern. The abdominal X-ray can see the liquid-gas plane.
4.myocardial infarction
History of coronary artery disease with sudden onset, sometimes with pain limited to the upper abdomen. Electrocardiogram shows myocardial infarction images, and serum cardiac enzymes are elevated. Blood and urine amylase are normal.
VII. Complications
Early complications include water and electrolyte disturbances, hypocalcemia, and hand and foot twitching. The later stage may be complicated by glandular abscesses, pseudocyst formation, and may leave chronic pancreatitis. When the pancreatic parenchyma is inflamed, the pancreatic islet cells are also damaged, affecting glucose metabolism, so it can be complicated by diabetes. When a large amount of exudate including pancreatic fluid flows into the abdominal cavity and causes diffuse peritonitis, shock or even death can occur.
VIII. Treatment
1.Non-surgical treatment
For the main treatment measures. In mild cases, sedation, analgesia (morphine is contraindicated) and antispasmodics such as atropine, scopolamine, bromopamine tylenol, pethidine hydrochloride, chlorpromazine hydrochloride, etc. are used. Acupuncture therapy can also be used to relieve pain, and Chinese herbal medicine to clear dampness and heat and regulate qi to relieve pain. In severe cases, with abdominal distension, peritonitis and signs of shock, fasting, gastrointestinal decompression, intravenous fluids (to maintain water and electrolyte balance), blood transfusion, continuous intravenous nutrition to maintain the supply of calories, and a large amount of vitamin B, C and antibiotics, because the causative agent is not easy to determine, the need to use the pancreatic fluid excreted in a higher concentration of drugs such as chloramphenicol and other broad-spectrum antibiotics.
If the blood calcium is low, 10% calcium gluconate should be given, especially in hemorrhagic pancreatitis. If the child has elevated blood glucose, appropriate amounts of insulin and potassium chloride should be added to the glucose injection. Gastrointestinal motility can be gradually restored within 3 to 4 days. When the child’s abdomen is no longer distended and can vent from the anus and has an appetite, he can start to eat a small amount of food, mainly carbohydrates, accompanied by protein, and fat should be restricted for a longer period of time.
2.Surgical treatment
Surgery should be considered only in the following cases: if non-surgical treatment is ineffective, if the fever persists, if the spirit is not good, if the abdominal distension, abdominal muscle tension, and if the pressure pain does not decrease, surgical exploration and abdominal drainage should be performed; if the diagnosis is not clear and other surgical emergencies cannot be excluded, surgery should be performed as soon as possible; if the complication is a limited abscess and a huge pancreatic pseudocyst, incision and drainage or internal drainage with the digestive tract should be performed.
IX. Prognosis
Acute pancreatitis generally disappears after about 3-7 days of non-surgical treatment, and gradually heals. Hemorrhagic, necrotic pancreatitis is serious and can lead to death due to shock, longer recovery period after acute remission and formation of limited abscesses, and can be followed by pseudocysts of the pancreas.
Ten, prevention
Avoid overeating, timely treatment of the pancreatic bile duct and other diseases that can damage the pancreas.