The difference in mean hospital stay and the need for intensive care was significant in children with higher CTSI score. Table 6 shows that the difference in ICU admission and overall hospital stay was statistically significant in children with higher CTSI score (P=0.001 and 0.005, respectively).
Like adults, the diagnosis of acute pancreatitis in children is based on revised Atlanta classification. It is defined as inflammation of the pancreas when two of the following three criteria are present: clinical symptoms associated with acute pancreatitis (abdominal pain, nausea and vomiting, back pain), an increase of serum amylase and/or serum lipase levels of three times upper limit of normal and imaging findings typical of acute pancreatitis 23,24. The main presenting complaint in acute pancreatitis is abdominal pain. This was typically located in epigastrium in 77% of our patients, while it was generalized in 15% of the patients. Only three (6%) patients gave a definite history of pain radiating to the back. This is associated with vomiting in 80% of the patients while fever in 25% of the patients. The increase in enzyme levels should be substantial because increased levels are also observed in other conditions. The sensitivity of serum amylase in our study was 74.5%, while that of serum lipase was 91%. Various authors have reported these values to range from 50 to 80% for serum amylase and up to 100% for serum lipase, respectively. The patients with increasing CTSI show increased serum markers but as shown in Table 3 these values are not statistically significant. The reason for this discrepancy could be the small number of patients in each group. Perhaps a study with a larger number of patients may answer this question more clearly. Normal values of these enzymes do not rule out acute pancreatitis 24. This applies to leukocytosis as well. Some investigators have reported other biochemical markers of the disease and these include interleukin-6, C-reactive protein, and procalcitonin 24. Imaging is another very important criterion in the Atlanta classification. Its role is to confirm the clinical findings and the degree of involvement and if feasible to investigate the cause of pancreatitis. At our center, we performed emergency ultrasonography followed by CT scan. The main findings detected on emergency ultrasonography were diffusely enlarged pancreas, poorly defined borders, and peripancreatic fluid collection 25. CT findings include an increase in pancreatic size with ill-defined borders and peripancreatic fluid. Necrosis is suggested by areas of low enhancement or no enhancement on contrast CT scan. CT scan is considered the investigation of choice because it establishes the diagnosis accurately, can stage the disease, can detect pleural effusion and ascites, quicker thereby decreasing the need or dose for sedation in children, and higher sensitivity 26,27. We performed the CT scan after 48 h or more of symptom onset because an early CT may undervalue ultimate morphologic severity of the disease, as the necrosis may not be visible on CT within 24–48 h of symptom onset 26. Pancreatic inflammation is classified into five groups (Balthazar scoring) 28. CTSI is calculated by the addition of Balthazar and necrosis score (Table 2). By assessing necrosis and local complications, CTSI allows assessment of the severity of the inflammatory process and helps categorize patients for the treatment options including ICU admission. CTSI effectively predicts morbidity and mortality in children with pancreatitis. We can clearly see in our patients that patients with higher CTSI have high rate of complications, both early and late (Table 6). In their study Balthazar et al.28 found an excellent correlation between necrosis, the length of hospitalization, development of complications, and mortality: patients with a CTSI up to 3 showed a morbidity rate of 8% and a mortality rate of 3%. However, in patients with CTSI at least 7 a higher rate of both local and systemic complications was observed, higher rate of ICU admission, and the rate of morbidity and mortality was 92 and 17%, respectively. In our study also we found that children with higher CTSI had a longer hospital stay and they required intensive care during that stay as well. In our study, one (11%) patient had died out of nine patients with CTSI of 7–10 (severe). We found that the patients with higher CTSI scores had a more complicated course in the form of local complications, need for surgical intervention, and longer hospital stay (Tables 4 and 6). In 2000, Simchuk et al. 27 in their study on adults found that there was a correlation of CTSI with mortality rate, hospital stay, and need for necrosectomy.
The outcome in acute pancreatitis is related to the development of complications secondary to necrosis which therefore entail surgical intervention, need for ICU admission, and increased hospital stay. Therefore, for better outcome, detection of necrosis and staging of the severity of the disease must be early and objective. For this, the detection system should have high sensitivity and a positive predictive value. It should be able to detect necrosis early in the course of the disease. CT is 80–90% accurate in the detection of pancreatic necrosis. Various scoring and imaging systems have been used to achieve this in children with acute pancreatitis. Hashimoto et al. 29 reported that pediatric acute pancreatitis severity scoring system is best in the pediatric age group. But they have admitted that CTSI could not be done in all the patients.
Thus, we recommend CTSI in children of acute pancreatitis for earlier and better recognition of its severity and therefore better outcome as compared with other scoring systems.
Treatment of acute pancreatitis is mainly conservative. Restoring hemodynamics, rehydration, correction of disorders of acid–base balance together with pain control is the initial goal. The complications observed in children with pancreatitis can be immediate or late. Immediate complications may include shock and multiorgan failure. The occurrence of acute systemic complications is associated with already present comorbid conditions 24,25. Since there are fewer comorbid conditions in children as compared with adults, the incidence of acute complication following acute pancreatitis is less as was observed in our study also. In our study, the main reasons for surgical intervention during initial admission were fever, toxemia, and increasing abdominal distension. These features indicate the development of necrosis and/or infected ascites. The most common late complication to affect children following pancreatitis is the formation of pseudocysts. The incidence of pseudopancreatic cyst is higher in children who develop traumatic pancreatitis. Small asymptomatic pseudocysts with no evidence of complication is managed conservatively 25. Larger, mature, and symptomatic pseudocysts are managed by surgical drainage (open, laparoscopic, or endoscopic). Acute recurrent pancreatitis is reported to occur in 15–35% of the patients with acute pancreatitis 30. The incidence of CP is even lesser. But the morbidity associated with acute recurrent pancreatitis and CP is significant. The mainstay of treatment in CP is pain control which may require opioids. The other drugs given are pancreatic enzymes and antioxidants. Endoscopic or surgical intervention may be needed in nonresponsive patients 31. Six percent of our patients developed CP. All of them were managed by endoscopic intervention (two of them required balloon dilatation of the main pancreatic duct while one required stent insertion).
There are no conflicts of interest.
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