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Pediatric pancreatitis

Key sources
The following summarized guidelines for the evaluation and management of pediatric pancreatitis are prepared by our editorial team based on guidelines from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN 2021; 2018), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2018), and the INternational Study Group of Pediatric Pancreatitis: In search for a cuRE (INSPPIRE 2018; 2017).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria: as per NASPGHAN 2018 guidelines, diagnose pediatric acute pancreatitis according to the INSPIRE criteria.
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2.Diagnostic investigations

Laboratory testing: as per NASPGHAN 2018 guidelines, obtain liver enzymes (ALT, AST, GGT, ALP, bilirubin) triglycerides, and calcium in patients with a first-time attack of acute pancreatitis.
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  • Cross-sectional imaging (acute pancreatitis)

  • Cross-sectional imaging (chronic pancreatitis)

  • MRCP/ERCP/EUS

  • Genetic testing

  • Nutritional assessment

  • Screening for celiac disease

3.Diagnostic procedures

Upper gastrointestinal endoscopy: do not perform upper gastrointestinal endoscopy routinely in pediatric patients with acute pancreatitis. Determine its indication on a case-by-case basis.
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4.Medical management

Intravenous fluids: as per NASPGHAN 2018 guidelines, administer crystalloids either with lactated Ringer or normal saline in the acute setting for initial resuscitation of pediatric patients with acute pancreatitis. Administer a bolus of 10-20 mL/kg in case of hemodynamic compromise. Provide 1.5-2 times maintenance IV fluids with monitoring of urine output over the next 24-48 hours in pediatric patients with acute pancreatitis.
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  • Pain management

  • Pancreatic enzyme replacement therapy

  • Antibiotics

  • Corticosteroids

  • Therapies with no evidence for benefit

5.Inpatient care

Serial clinical and laboratory assessment
Monitor vitals at least every 4 hours during the first 48 hours of admission and during periods of aggressive hydration to monitor oxygen saturation, BP, and respiratory rate in patients admitted to an inpatient ward. Adjust the frequency based on clinical status. Obtain specialist assessment in case of abnormalities in vital signs.
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Monitor BUN, creatinine, and urine output routinely during the first 48 hours as a marker of appropriate fluid management and to screen for AKI. Obtain nephrology assessment in case of abnormalities.
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  • Serial imaging assessment (acute pancreatitis)

  • Serial imaging assessment (chronic pancreatitis)

6.Nonpharmacologic interventions

Nutritional support: as per ESPGHAN 2018 guidelines, provide a regular diet in pediatric patients with chronic pancreatitis, with or without exocrine pancreatic insufficiency.
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7.Specific circumstances

Patients with biliary pancreatitis: as per NASPGHAN 2018 guidelines, perform cholecystectomy before discharge in patients with mild uncomplicated acute biliary pancreatitis.
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  • Patients with necrotizing pancreatitis

  • Patients with autoimmune pancreatitis (clinical presentation)

  • Patients with autoimmune pancreatitis (laboratory tests)

  • Patients with autoimmune pancreatitis (diagnostic imaging)

  • Patients with autoimmune pancreatitis (histopathology)

  • Patients with autoimmune pancreatitis (corticosteroids)

  • Patients with autoimmune pancreatitis (management of relapse)

  • Patients with autoimmune pancreatitis (long-term surveillance)

  • Patients with congenital pancreatic anomalies

8.Follow-up and surveillance

Surveillance for complications: as per ESPGHAN 2018 guidelines, monitor for pancreatic exocrine insufficiency every 6-12 months with fecal elastase or 72-hour fecal fat collection in pediatric patients with chronic pancreatitis.
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