A 14-year-old male was re-admitted with emesis 1 week after surgery for acute appendicitis. After discharge he had continued to have abdominal pain and emesis that initially was 1-2 times/day, but now was 4-5 times. The emesis was non-bilious and non-bloody, and was of fluid and food only. The abdominal pain was generalized although there was some increased tenderness around the incision site. There was no radiation. He was urinating less frequently but without pain or discharge. He was passing stools that were small without pain, blood or mucous. He also had an intermittent low grade fever and diaphoresis with the emesis but not otherwise. He denied sick contacts, travel or sexual activity. The past medical history and family history were non-contributory. The review of systems showed a mild weight loss of 5 pounds but was otherwise negative.
The pertinent physical exam showed a fatigued male with normal vital signs who was afebrile and with growth parameters in the 75-90%. HEENT showed tacky mucous membranes. Lungs and heart were normal. Abdomen revealed a healing incision, hypoactive bowel sounds, and no organomegaly or masses. There was tenderness that was more epigastric to periumbilical without radiation. There was no costovertebral angle tenderness, suprapublic tenderness or fluid wave detected. Genitourinary examination showed a Tanner V male with normal phallus and testicles. There were no hernias. Rectal examination was normal and guiac was negative.
The laboratory evaluation of a complete blood count, and urinalysis were negative. He had a mild hypochloremic metabolic acidosis and BUN of 25 mg/dl and creatinine of 1.3 mg/dl. He had upper level normal transaminases, and total and direct bilirubin. C-reactive protein was 0.9 mg/dl and erythrocyte sedimentation rate was 28 mm/hr. His amylase and lipase were elevated at approximately 2 times normal. The radiologic evaluation of an abdominal ultrasound was negative including intact biliary system, pancreas of normal size, and a normal amount of peritoneal fluid. The diagnosis of of continued post-operative abdominal pain with increasing emesis, moderate dehydration and elevated pancreatic enzymes was made.
The patient’s clinical course included treatment with fluid resuscitation which remedied the electrolyte abnormalities and dehydration. Over hospital day 1, he had increasing frequency of emesis and generalized pain. He was treated with analgesics and antiemetics. In the morning of hospital day 2, his pancreatic enzymes increased to ~ 2.5 x normal and later that evening he began to feel better and had decreased pain and emesis. On hospital day 3, the pancreatic enzymes had increased to ~1.8 times normal. Over the next 24 hours, he continued to improve with resolution of the emesis, and markedly decreased pain. His pancreatic enzymes were now just above normal. He was discharged home with a diagnosis of abdominal pain and emesis of unknown etiology and he had resolution of his symptoms by 1 day after discharge. His followup laboratory testing one week later was normal.
Acute pancreatitis (AP) is a reversible process that involves interstitial edema, inflammatory infiltrates, hemorrhage and necrosis of the pancreas to varying degrees. AP’s incidence is increasing in recent years but the reason for the increase is unknown. The common causes of AP includes biliary abnormalities, medication, idiopathic, systemic disease, trauma, infectious, metabolic and hereditary.
Most children with AP present with abdominal pain that is usually epigastric but may be diffuse. Radiation may occur to the back but is less common. Patients often have nausea and emesis. Abdominal distension, fever, jaundice, ascites and pleural effusions can occur. Irritability is also common in young children. The most common abdominal mass in AP are pseudocysts. Common radiographic changes include pancreatic edema, heterogeneity, and peripancreatic fluid.
AP’s treatment is usually supportive with hydration, nutrition and analgesia. Mild AP cases resolve within 7 days. Early onset complications include shock and multi-organ system dysfunction particularly of the kidney and lung. Late onset complications are organ necrosis and pseudocyst formation. About 15-35% of patients may have a recurrence of acute pancreatitis also.
AP is a clinical entity whose generally accepted definition using the 1992 Atlanta consensus conference criteria is for the patient to have 2 of 3 criteria:
- Abdominal pain compatable with AP
- Elevated amylase/lipase that are 3x or more above normal
- Anatomical changes to the pancreas on cross-sectional imaging
Questions for Further Discussion
1. What is included in the differential diagnosis of abdominal pain? See Acute Abdominal Pain Througout the Ages and What Causes Recurrent Abdominal Pain?
2. How does recurrent pancreatitis differ from acute pancreatitis?
3. What are indications for a surgical consultation in the setting of acute abdominal pain?
- Specialty: Gastroenterology
- Age: Teenager
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Bai HX, Lowe ME, Husain SZ. What have we learned about acute pancreatitis in children? J Pediatr Gastroenterol Nutr. 2011 Mar;52(3):262-70.
Mekitarian Filho E, Carvalho WB, Silva FD. Acute pancreatitis in pediatrics: a systematic review of the literature. J Pediatr (Rio J). 2012 Mar-Apr;88(2):101-14.
Dzakovic A, Superina R. Acute and chronic pancreatitis: surgical management. Semin Pediatr Surg. 2012 Aug;21(3):266-71.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital