Acute Pancreatitis in the Pediatric Population

Nicole Vantress Spring 2013

Significance
Pediatric pancreatitis remains poorly understood despite increasing incidence of morbidity and mortality. 1 In up to 35% of children with acute pancreatitis, a cause may not be identified.2

Not many set guidelines/research studies specific to pediatrics

What is Acute Pancreatitis?

Definition: Inflammation of the pancreas usually from the premature activation of digestive enzymes.3

Pathophysiology
Trigger Event Premature activation of proteolytic digestive enzymes

Initial insult results in activation and release of trypsin into the cytoplasm of the pancreas

Release of cytokines, inflammatory mediators, and inflammatory cell recruitment

Onset of pain usually occurs 24 to 36 hours after the peak of cytokine production

Onset of systemic complications and distant organ failure occurr 1 to 3 days later

Causes of Acute Pancreatitis in Children

Physical injury Medications Gallstones Systemic illness Problems in the anatomy of the ducts in the liver or pancreas2

In up to 35% of children with acute pancreatitis, a cause may not be identified.2

Symptoms
Pain usually begins in the upper abdomen that may last for a few days.4 Swollen and tender abdomen

Nausea
Vomiting

Fever
Rapid pulse

Diagnosis
Blood test Abdominal ultra sound CT scan

Lab Values Diagnosis

Lipase and Amylase Lipase greater than or equal to 7 x normal upper limit within 24 hours of presentation.1 Serum amylase is elevated in at least 75% of cases of acute pancreatitis and remains elevated for 5-10 days in most patients. However, amylase lacks specificity for pancreatitis because it can be elevated in other disorders. Lipase is more specific for pancreatitis, but may not always be elevated. 3 Note that both enzymes may be increased in other conditions such as renal failure.

Other Tests of Pancreatic Function

Secretin stimulation test Glucose tolerance test 72-hr stool fat test
monitoring

Complications
Nutrient Malabsorption/Losses5 Reduced oral intake Potential to lead to more serious diseases6
Breathing problems Diabetes Infection Kidney Failure Malnutrition Pancreatic Cancer (more in chronic pancreatitis) Pseudocyst

Treatment
Medications:
Abx Bile Salts Diruetics Insulin Octreotide Opiates Pancreatic Enzymes Somatostatin inhibits pancreatic secretion H2-receptor antagonists reduce pancreatic stimulation

Treatment Cont
Usually resolves on its own4 Lessen pain Prevent complications Severe cases, a child may need nutrition support for 3 to 6 weeks while the pancreas slowly heals.4

Nutritional Needs
There is increased protein catabolism, energy expenditure, insulin resistance and dependence on fatty acid oxidation to provide energy substrates.

Pancreatitis is a hypermetabolic, hypercatabolic disease in which energy expenditure can increase as much as139%.5
Metabolic needs similar to sepsis7 Acute pancreatitis more hypermetabolic than chronic

MNT
Withhold oral feeding Support with IV fluids Nutritional support in acute pancreatitis is indicated when there is actual or anticipated inadequate oral intake for 57 days. This period may be shorter in those with pre-existing malnutrition.7
Importance of early enteral feeds EN preferred over PN

Early Feeds
Initiation of feeds < 24 hrs in the PICU, has shown better tolerance.8 Early feeding leads to:
Less gut permeability Decreased release of inflammatory cytokines Overall decrease in infectious morbidity and hospital length of stay.5

EN vs PN
Enteral is preferable to parenteral nutrition.9
More cost effective without added risk of hospitalacquired infection found with PN

TPN has high risk for infection Benefit from feeding the gut8

Enteral Nutrition Support

NJ tube should be chosen if pancreatic rest is still needed. 40-60 cm below ligament of Treitz10 NJ not recommended for everyone; only those with trouble for tolerance or high risk or aspiration.

Not enough research for all EN pediatric patients

Formula
Polymeric formulas shown to be tolerated with NJ feeds.9 Peptide-based formulas such as Peptamen or Peptamen Jr11
Peptides Antioxidants Omega-3s MCTs Higher in protein

Nutrition Goals
In the early stage of severe pancreatitis, avoid overfeeding, but still meet elevated needs. Provide adequate protein to support acute phase protein synthesis. Monitor for hyperglycemia and insulin resistance May also check:
Prealbumin/CRP Stool Lipase/amylase

Nutrition Goals Continued

Once abdominal pain resolves and amylase and lipase are decreasing towards normal can usually advance to clear liquid diet.12

Progress to oral diet includes six small meals

Depending on damage/function of pancreas, may need pancreatic enzymes and/or low fat diet.

Progress to regular diet with or with out pancreatic enzymes

Prognosis
Mortality less common than in adult population13 Outcome depends on severity, but most kids can eventually return to normal diet

References
1. Coffey MJ, Nightingale S, Ooi CY. Serum lipase as an early predictor of severity in pediatric acute pancreatitis. Journal of Pediatric Gastroenterology Nutrition. Feb 10, 2013. Available at http://www.ncbi.nlm.nih.gov/pubmed/23403441. Accessed April 11, 2013. Lowe ME, Greer JB, Srinath A. Fact sheet- acute pancreatitis in children. National Pancreas Foundation. 2013. Available at http://pancreasfoundation.org/wpcontent/uploads/2010/04/Fact-Sheet-Acute-Pancreatitis-in-Children.pdf. Accessed April 11, 2013.

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3.

Khokhar AS, Seider DL. The pathophysiology of pancreatitis. Nutrition in Clinical Practice. 19:5, 2004.
Pancreatitis. John Hopkins Childrens Center. Available at http://www.hopkinschildrens.org/Pancreatitis.aspx. Accessed April 13, 2013. The A.S.P.E.N. Adult Nutrition Support Core Curriculum 2nd Edition. 2012 Pancreatitis. Mayo Clinic. Janurary 15, 2011. Available at http://www.mayoclinic.com/health/pancreatitis/DS00371/DSECTION=complications. Accessed April 11, 2013.

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References Cont
7. Mahan KL, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th Ed. Elsevier. 2013. Sanchez C, Lopez-Herce J, Carillo A, Mencia S, Vigil D. Early transpyloric enteral nutrition in critically ill children. Nutrition 2007;23:16-22 Mehta NM, Compher C. A.S.P.E.N. Clinical guidelines: Nutrition support of the critically ill child. Journal of Parenteral and Enteral Nutrition. 2009; 33:260-276. Available at http://pen.sagepub.com/content/33/3/260.full?patientinform-links=yes&legid=sppen;33/3/260#ref-50. Accessed April 12, 2013. OKeefe SJ, Broderick T, Turner M, Stevens S, OKeefe JS. Nutrition in the management of necrotizing pancreatitis. Gastrointestinal Hepatol. 2003;1:315-321. Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med. 2006;34:1033-1038. Forsmark CE. Chronic pancreatitis. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger and Fordtrans Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. Philadelphia,PA: Sauders; 2002: 943-969. Werlin SL, Kugathasan S, Frautschy BC. Pancreatitis in children. J Pediatr Gastroenterol Nutr 2033, 37:591-595 8.

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THANK YOU!