The management of acute, uncomplicated pancreatitis in childhood is mainly supportive. The patient should be provided adequate hydration, pain relief and pancreatic rest.55 The child should be made nil per os in severe cases, which will decrease the cephalic, gastric and intestinal phases of pancreatic secretion. Continuous or intermittent nasogastric suction may be required in cases with ileus or persistent emesis. If the child is expected to be without enteral feedings for more than 3 days, parenteral nutrition should be initiated to prevent protein catabolism. Recent studies have suggested that nasojejunal feedings with an elemental diet, which bypass the duodenum completely and therefore do not potently stimulate pancreatic secretion, are just as safe as parenteral nutrition in adults with severe, acute pancreatitis. Nasojejunal feeds are also less costly, have fewer metabolic complications, and may shorten the length of stay.61 Antibiotics are not normally indicated, unless there are signs of sepsis, necrotic pancreatitis, or multiorgan system failure. Histamine (H2) receptor antagonists may help to prevent stress ulceration by reducing duodenal acidification. Current research targeting the inflammatory cascade as described in the Pathophysiology section of this chapter may also lead to therapies that are beneficial for acute pancreatitis, regardless of the etiology.
Adequate treatment of pain in acute, severe pancreatitis in childhood can be challenging. It may be difficult to relieve a child's pain completely. Opiates have been reported to worsen symptoms by increasing spasms of the sphincter of Oddi. Meperidine (Demerol®) is the analgesic of choice of all the pure opiate agonists for acute pancreatitis, because it produces the least increase in enterobiliary pressure. We have also used hydromorphone hydrochloride (Dilaudid®) as a continuous infusion in many children with severe, acute pancreatitis, as well as in chronic and complicated pancreatitis, with excellent pain control.
Complications of chronic pancreatitis include pancreatic atrophy with resultant exocrine and/or endocrine insufficiency. Severe, prolonged cases may require insulin, pancreatic enzyme replacement and an elemental or low-fat diet to optimize absorption once enteral feedings are reinitiated.
The major cause of mortality in pediatric patients with acute pancreatitis is septic complications. These are believed to arise from bacteria that have translocated across the intestinal epithelium and disseminated systemically via the mesenteric lymph nodes and lymphatics. This can result in pancreatic abscess, infected pseudocyst, or even necrosis of the gland. Evidence of infection within a defined area can be obtained with fine-needle aspiration under ultrasound or CT guidance. Gram stain and culture of the aspirate are clinically useful. Often, enteric organisms are recovered, such as Escherichia coli, Klebsiella species and other Gram-negative rods.62 In the patient with necrotizing pancreatitis and organ failure, it is reasonable to initiate treatment with an antibiotic that has broad-spectrum activity against both aerobic and anaerobic bacteria.55
These infections necessitate surgical intervention. However, whether a sterile abscess, pseudocyst or necrosis requires operative management is still controversial.55 Antibiotics and intensive care usually provide adequate support for the patient who has sterile necrosis. The presence of persistent ileus, bowel perforation, portal vein thrombosis and multisystem organ failure are 'red flags' that indicate urgent surgical intervention. Infected pancreatic necrosis is an absolute surgical indication, requiring necrosectomy (surgical debridement). Necrosectomy is thought to stop the progression of the necrotizing process and resultant multi-organ failure. Debridement, rather than total or partial pancreatic resection, is preferred, as it preserves exocrine and endocrine function. It may be necessary for the patient to undergo multiple reoperations, or continuous lavage with catheters left in the retroperitoneum. Necro-sectomy itself may cause further complications, such as sepsis, hemorrhage, wound infection and fistulas of the pancreas, intestine and biliary system.
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