Acute Pancreatitis (<18 years old)

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Acute Pancreatitis (<18 years old)

Admission for mild pancreatitis

Admit to Floor

Fluids pathway

Caution patients with pre-existing organ failure: watch for signs of pulmonary edema (tachypnea, hypoxia, increased work of breathing)

Evaluate the following criteria:

  • Abdominal pain consistent with acute pancreatitis
  • Serum lipase or amylase ≥ 3x upper limit of normal
  • Characteristic findings of acute pancreatitis on transabdominal ultrasonography, MRI or contrast-enhanced CT if obtained

NS Bolus

Change fluids to IV + PO = 1x maintenance OR discontinue fluids

Inclusion Criteria
  • Abdominal pain concerning for pancreatitis
Exclusion Criteria
  • Complex history of abdominal surgery

If US concerning for pancreatic complications, consider further imaging with CT or MRI.

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Gamma-Glutamyl Transferase (GTT), Serum
Triglyceride, Serum
C-Reactive Protein (CRP), Serum
Lipase, Serum
Amylase, Serum
Ultrasound Abdomen, Complete

Nutrition Pathway

(mild pancreatitis only)

Transition to PRN acetaminophen or NSAID

Evidence of Local Complications of Acute Pancreatitis:

  • Acute peripancreatic fluid collection
  • Pancreatic pseudocyst
  • Acute necrotic collection
  • Walled-off necrosis
  • Gastric outlet dysfunction
  • Splenic and portal vein thrombosis
  • Colonic necrosis

Diet Clear Liquid

Evaluate for other etiologies of acute abdominal pain

Continued concern for pancreatitis?

Consult a pediatric gastroenterologist

SIRS/Organ Failure/Local Complications?

Responsive to initial fluid bolus?

Continue resuscitation and admit to ICU

Consult Pediatric Gastroenterology for Management of Nutrition and Pain

Admit to ICU

Patient evaluation #3 (12 hours after eval #2):

  • Obtain renal function panel and CBC
  • Any of the following present?
  • BUN unchanged or increased from admission
  • Hematocrit > 44
  • UOP < 1 mg/kg/hr or 30 mL/hr in older children
  • Persistent tachycardia, hypotension, prolonged capillary refill, poor skin turgor

Reassess for SIRS/Organ Failure/Local complications and consider ICU consult if not already in ICU

Admission for moderate/severe pancreatitis

Change fluids to 1x maintenance and add potassium

NS Bolus

Analgesia Pathway

Meets advancement criteria?

Reassess advancement criteria

Goal: Start enteral nutrition within 48 hrs of admission

Advance to regular, age-appropriate diet, no-fat restriction

Imaging is not necessary for diagnosis of pancreatitis, but may help to determine etiology and assists in the classification of pancreatitis as mild, moderate, or severe, which helps determine management.

Amylase and Lipase may be elevated due to non-pancreas related etiologies.

  • Amylase: increases 2-12 hours after insult, peaks at 12-72 hours.
  • Lipase: increases 4-8 hours after insult, peaks at 24 hours.

Clinical Signs of Organ Dysfunction:

  • CV: hypotension (less than 5th percentile for age), capillary refill > 5 seconds, oliguria, unexplained metabolic acidosis
  • Renal: Cr ≥ 2x upper limit for age or 2-fold increase in baseline
  • Hepatic: total bilirubin ≥ 4 mg/dL or ALT 2x upper limit for age
  • Heme: platelets < 80,000/mm3 or INR >2

Pain well controlled?

Address the following and reassess advancement criteria:

  • Pain: is it well controlled?
  • Nausea: consider zofran scheduled or PRN
  • Local complications: has disease progressed/worsened?
  • Etiology: have you treated the underlying cause?

Diet advancement criteria (assess Q6 hours):

  • Desire to eat
  • No vomiting
  • Positive bowel sounds
  • Pain should NOT be a reason to limit diet.

Pediatric SIRS Criteria: ≥ 2 criteria: (one of which must be abnormal temperature or leukocyte count):

  • Core Temp > 38.5°C or < 36°C.
  • Tachycardia
  • Tachypnea or mechanical ventilation
  • Leukocyte count elevated or depressed for age (not secondary to chemotherapy-induced leukopenia) or > 10% immature neutrophils.

NG/NJ feeds (start with clears - pedialyte)

Pain meds based on severity of pain and ability to tolerate PO. NSAIDs should not be added until Cr has normalized and/or there are no signs of AKI

Acetaminophen suspension
Ibuprofen suspension
Morphine injection
Acetaminophen injection
Ketorolac injection

Patient evaluation #2 (12 hours after eval #1): any of the following present?

  • UOP < 1 mg/kg/hr or 30 mL/hr in older children
  • Persistent tachycardia, hypotension, prolonged capillary refill, poor skin turgor

NS Bolus

Parenteral nutrition (last resort)

  • Morphine/Dilaudid IV scheduled or PCA
  • Bowel regimen (Miralax or Colace)
  • Consider other causes of pain
  • Local complications
  • Psychosocial causes
  • Other etiologies

Patient evaluation #1 (Fluid responsiveness): any of the following present?

  • UOP < 1 mg/kg/hr or 30 mL/hr in older children
  • Persistent tachycardia, hypotension, prolonged capillary refill, poor skin turgor

Reassessment #1 in 6 hours

D5 NS infusion

Potential etiologies of pediatric pancreatitis

  • Biliary/Obstructive Factors
  • Gallstones
  • Biliary Sludge
  • Pancreas divisum
  • Choledochal cyst
  • Sphincter of Oddi dysfunction
  • Annular pancreas
  • Medications
  • L-Aspariginase
  • Steroids
  • Valproic Acid
  • 6-MP/Azathioprine
  • Mesalamine
  • Furosemide
  • Tacrolimus
  • Systemic Disease
  • Sepsis
  • Shock
  • Inflammatory Bowel Disease
  • Hemolytic Uremic Syndrome
  • Henoch-Schönlein Purpura
  • Kawasaki Disease
  • Systemic Lupus Erythematosus
  • Polyarteritis Nodosa
  • Juvenile Rheumatoid Arthritis
  • Anorexia Nervosa
  • Trauma
  • Blunt Injury
  • ERCP
  • Infection
  • Mumps
  • Measles
  • Coxsackie
  • Echo
  • Iota
  • Influenza
  • Epstein-Barr virus
  • Mycoplasma
  • Salmonella
  • Other Gram-Negative bacteria
  • Metabolic Diseases
  • DKA
  • Hyperlipoproteinemia
  • Inborn Errors of Metabolism
  • Hypercalcemia
  • Idiopathic
  • Autoimmune
  • Genetic (CFTR, SPINK1, PRSS1, and CTRC mutations)