|ECR 2019 / C-1542|
|Acute pancreatitis in pediatric age|
Findings and procedure details
Imaging plays an important role in the management of selected cases of acute pancreatitis, complementing laboratory investigations or when only 1 out of 3 diagnostic criteria of pancreatitis is present.
These are the common imaging findings in patients with acute pancreatitis:
Plain chest X-ray: (These findings are not specific for acute pancreatitis but important for disease severity).
- pleural effusion
- ARDS (Acute respiratory distress syndrome)
Plain abdominal X-ray: (These findings are necessary for a differential diagnosis and to exclude perforation)
- colon cut-off sign
- sentinel loop sign
- calcified gallstones or pancreatic stones, or retroperitoneal gas
Ultrasonography: (best initial imaging study to diagnose and monitor children).
- Dilatation of the pancreatic duct (the most reliable diagnostic feature), Fig. 10
- Biliary tree abnormalities.
- It is useful to determine the pancreatic size, the echogenicity of the parenchyma, and other extrapancreatic findings (peripancreatic fluid or localized fluid collections.)
Some differences should be taken into account between the pediatric
pancreas and the adult pancreas, in children we find that:
- The pancreas is larger than the adult pancreas.
- The pancreatic head tends to be more prominent than the body and tail.
- In newborns the pancreas is hyperechoic to the liver and in the neonatal period is isoechoic or slightly hyperechoic relative to the liver.
CT scanning after 72 hours: (useful when the diagnosis is uncertain, to assess severity and to detect necrosis. Used to calculate the Modified-CTSI Mortele Index Fig. 8 and Fig. 9. IV contrast material is mandatory unless there is a contraindication):
- Pancreatic hypodensities, enlargement, heterogeneity,…
- Inflammatory changes in the peripancreatic fat (thickening of the retroperitoneal fascial planes, mild stranding of the fat.)
- Homogeneous enhencement in mild cases, heterogeneous in advanced cases, and no enhancement in cases of necrotizing pancreatitis.
- Collections in the lesser sac and pararenal space.
Endoscopic Retrograde Cholangiopancreatography (ERCP): should be performed in pancreatitis of unknown cause.
A 13-year-old boy who was admitted to the emergency room with 24 hour pain in the upper right-left quadrant radiated to the back. There was no history of abdominal trauma. Afebrile. A physical examination upon admittance showed normal vital signs and tenderness in the epigastric area. Laboratory tests showed amylasemia of 3432 U/L and GOT 523 U/L, GPT 717 U/L and CRP< 0.4mg/dL.
The diagnosis of pancreatitis was made as 2 out of 3 diagnostic criteria are present: characteristic abdominal pain and elevated levels of pancreatic enzymes in blood urine at least 3 times upper limits of normal. Ultrasound is the first imaging technique to be used in acute pancreatic evaluation.
Abdominal ultrasound showed a gallbladder with tiny cholesterolomas adhered to the wall, microlithiasis, and biliary sludge in the infundibulum Fig. 1, and indicated normal caliber of the intrahepatic and extrahepatic bile ducts. Pancreas not visible because of increased bowel gas secondary to aerophagia and ileus. Not localized fluid collections are visualized. Minimal amount of sub-splenic fluid Fig. 2 .
A diagnosis of mild acute pancreatitis without systemic complications was made and supportive treatment of intravenous fluids, analgesics and a liquid diet was started.
After 48-72h, the boy developed signs of respiratory distress such as tachypnea (50 bpm), nose flaring, hipoxemia (oxigen saturation of 93% with an oxygen therapy of 3 LPM) and intercostal retractions. Oliguria, tachycardia and lower fever (37.5º) also appeared. Due to the severity of his acute pancreatitis, a new blood test was performed: GPT 218, GGT 209, Amylase 2090 U/L, Lipase 2438 U/L and CPR 38,7 mg/dL, leukocytes 29×103/μL (90% neutrophils). In order to evaluate severity of acute pancreatitis and identify complications, a contrast-enhanced abdominal pelvic CT scan was then performed.
The CT scan showed homogeneous pancreatic enhancement Fig. 3 with inflammatory changes in the peripancreatic fat Fig. 4 (thickening of the retroperitoneal fascial planes and edema in the peripancreatic fat, mostly in the pancreatic tail). Peripancreatic fluid was detected in the right pararenal space Fig. 5, subhepatic and perisplenic space, extending to the pelvic cavity Fig. 6. Bilateral pleural effusion and left lower lobe consolidation Fig. 7.
Whereas in children anatomic anomalies, viral infections and trauma are the main causes of pancreatits, in this case report biliary sludge and microlithiasis are the most likely cause of his acute pancreatitis.
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