#139: Behind the Bellyache: Acute Pancreatitis

April 23, 2025 | By Sam Masur

Audio

Summary:

Do you develop acute belly pain when you think about pancreatitis? Grab your antiemetics and analgesics and stave off the belly pain for this inflammatory discussion! In this episode, we sit down with our expert pancreatologist, Dr. David Vitale, to discuss all things acute pediatric pancreatitis. He takes us through the causes, pathophysiology and treatment, as well as what the generalist should look out for.

Acute Pancreatitis Pearls

1. Pediatric acute pancreatitis (AP) is diagnosed when two out of three criteria are met: abdominal pain, serum amylase/lipase levels ≥3 times normal, or imaging findings consistent with AP.
2. The most common causes include idiopathic factors (24%), trauma (17%), systemic illnesses (15%), and structural abnormalities (14%), with the highest risk in children under five.
3. Early enteral nutrition, fluid resuscitation and supportive analgesia/antiemetics are mainstays of treatments. Gallstone pancreatitis requires timely management with ERCP and/or cholecystectomy during the same hospital admission.
4. The majority of children will only have one episode of pancreatitis, however 25-30% of children will go on to develop acute recurrent or chronic pancreatitis.

Pediatric Acute Pancreatitis Notes 

Definition:

The diagnosis of pediatric acute pancreatitis (AP) should follow the INSPPIRE criteria, as recommended by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). 

According to these criteria, the diagnosis of AP in pediatric patients requires at least two of the following three criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times the upper limit of normal, and (3) imaging findings consistent with AP. (1)

Pathophysiology:

AP is primarily characterized by the premature activation of pancreatic enzymes within the pancreas, leading to autodigestion and inflammation. This process results in the loss of intracellular and extracellular compartmentalization, which can be triggered by various factors such as obstruction of pancreatic ducts, genetic mutations, or metabolic disturbances. The inflammatory response activates visceral pancreatic and somatic peritoneal pain receptors, contributing to the severe abdominal pain experienced by patients. (1)

Etiologies: 

According to the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), the primary etiologies include:

• Idiopathic/Other (24%)
• Trauma (17%)
• Systemic illness (SIRS, autoimmune pathologies; 15%)
• Structural abnormalities (congenital causes like pancreas divisum, choledochal cysts; 14%) *most common in children <5 years of age.
• Drugs/toxins (10%)
• Infections (mumps, EBV, etc; 8%)
• Metabolic-related conditions including hypertriglyceridemia and obstructive gallstones. (1)

Work Up:

Start by getting the following labs: 

• CBC with differential (looking for leukocytosis, hemoconcentration secondary to dehydration)
• CMP (ensure includes electrolytes, total and direct bilirubin; looking for signs of liver injury and biliary stasis)
• Triglycerides
• Amylase & lipase. 

** Of note, lipase is more sensitive and specific for pancreatitis. It peaks later than amylase, and takes longer to return to normal. Amylase peaks earlier, more quickly and also returns to normal limits earlier. Expert opinion: Dr. Vitale encourages you to get both, because they can be valuable hints as to where in the disease time course the patient is.

Transabdominal ultrasound is the first choice imaging in pediatric patients due to being non-invasive and highly accessible. However, sometimes the pancreas or bile duct cannot be visualized; acute pancreatitis can be visualized in ~50% of ultrasounds. If you can see the pancreas, ductal system and gallbladder, and there is no evidence of pancreatitis, you can reasonably rule out pancreatitis. 

If the ultrasound is insufficient, the next imaging of choice would be abdominal CT with contrast or MRI. Per Dr. Vitale, both have a similar sensitivity of ~75%. CT is typically preferred if you just need to visualize the pancreas and your labs are reassuring against liver injury/biliary stasis. If you need to look at the bile ducts, utilize MRI. 

Magnetic response cholangiopancreatography (MRCP) is an MRI with a specific focus on the pancreas and bile duct. 

** Of note, the term “biliary sludge” refers to a mixture of particulate matter and bile that Dr. Vitale relates to “biliary sand”. Think of it as very very small gallstones. These are important because they can exit the gallbladder and cause obstruction of the pancreatic duct.

How do I predict the severity of pancreatitis in children?

In adults with pancreatitis, Ranson’s Criteria is used to predict mortality and can be a useful measure in determining severity. In children, scoring criteria for acute pancreatitis is not well-validated and not frequently used. 

However, data has shown that certain clinical and laboratory markers can be useful: 

• BUN (>14) at admission and persistent elevation within 24-48 hours is a significant predictor of severe acute pancreatitis. Combining high BUN with low albumin levels helps improve predictive accuracy. (2)
• A CRP level greater than 108 mg/L within 48 hours of admission is a strong predictor of SAP, with high sensitivity and specificity. (3)
• An elevated white blood cell (WBC) count on admission is associated with severe disease. A cutoff of 13.5 x 10^9/L has been identified as significant. (4)
• Younger age, particularly under 12 years, is associated with a higher risk of developing moderate to severe AP. (5)
• Cytokine Profiles: Elevated levels of interleukin-6 (IL-6) and monocyte chemotactic protein-1 (MCP-1) on admission have been validated as predictors of SAP. (6) 
• Computed Tomography Severity Index (CTSI): A CTSI score of ≥3 is associated with the need for admission to a Pediatric Special Care Unit, indicating severe disease. (7)

Treatment

Supportive care: 

The mainstays of treating acute pancreatitis includes rehydration with IV fluids, supportive care with analgesic and antiemetic medications and early enteral nutrition. 

For fluids, consider starting with an initial bolus followed by 1.5 times maintenance rate fluids as these patients are often severely fluid down due to vomiting, inability to tolerate PO and third-spacing.  The goal is to replete intravascular volume to restore and maintain vascular flow to essential organs. Dr. Vitale notes that early studies are demonstrating that Lactated Ringers (LR) are superior to Normal Saline (NS) for rehydration:

Regarding nutrition, early enteral nutrition (EEN) has been widely studied in adult patients with acute pancreatitis and has been shown to reduce length of hospital stay and associated morbidity. The American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) support this strategy, highlighting that it maintains gut mucosal integrity and prevents bacterial translocation, which can lead to infected pancreatic necrosis. (8, 9, 10) In children, the data is more limited, but has shown similar benefits. Bukowski et al. reviewed studies on EEN in children with AP and found that early feeding is safe and may decrease the length of hospitalization. (11)

Treatment disparities do exist and are important to highlight. Specifically, non-Hispanic Black (NHB) children are less likely to receive opioids and intravenous fluids compared to non-Hispanic White (NHW) children. NHB and Hispanic children also have longer hospital stays and higher hospital costs. (12) Additionally, younger children are less likely to be transitioned directly to oral nutrition compared to older children. (13)

Etiology-specific management: 

In addition to supportive care and rehydration, it is essential to treat any identifiable underlying etiologies. This includes removing offending medications/toxins, correcting any structural abnormality and/or metabolic deviation, and alleviating biliary obstructions. Specifically for gallstones, many patients are excellent candidates for endoscopic retrograde cholangiopancreatography (ERCP) to remove an offending stone. If you have a patient with gallstone pancreatitis, data shows that the patient should undergo a same-admission urgent cholecystectomy. 

Complications & Prognosis:

Complications:

The most common complication of AP is persistent pain. Rarely, you can see complications including pseudocysts, necrotizing pancreatitis or infected necrosis. You should have a suspicion for these potential complications if your patient is not improving over the course of a few days while hospitalized, or if they have fevers/persistent pain. In this case, consider repeat imaging.

Importantly, Dr. Vitale recommends being judicious in initiating antibiotics; reserve these for patients in which you have a high infectious concern. 

There is a low risk of pancreatic damage/endo- or exocrine dysfunction in patients with acute pancreatitis. This is more likely in patients with acute recurrent or chronic pancreatitis. Refer to our “part 2” episode to hear more about these pathologies.

At the 3 month follow up visit: Dr. Vitale recommends obtaining screening labs for all patients, including Hgb A1c, pancreatic elastase, fat-soluble vitamin levels (vitamin A, D, E and K), PT & INR. In patients with persistent pain, weight loss, or other symptoms that raise red flags regarding possible complications, obtain cross-sectional imaging. 

Prognosis:

Dr. Vitale tells families that approximately 70-75% of pediatric patients with acute pancreatitis will only have one episode. The other 25-30% will go on to develop acute recurrent or chronic pancreatitis. Refer to our “part 2” episode on acute recurrent and chronic pancreatitis and the prognosis for those patient populations!

Citations

1. Abu-El-Haija M, Kumar S, Quiros JA, et al. Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr. 2018;66(1):159-176. doi:10.1097/MPG.0000000000001715
2. Farrell PR, Hornung L, Farmer P, et al. Who’s at Risk? A Prognostic Model for Severity Prediction in Pediatric Acute Pancreatitis. J Pediatr Gastroenterol Nutr. 2020;71(4):536-542. doi:10.1097/MPG.0000000000002807
3. Walker H, Melling J, Jones M, Melling CV. C-reactive protein accurately predicts severity of acute pancreatitis in children. J Pediatr Surg. 2022;57(4):759-764. doi:10.1016/j.jpedsurg.2021.08.007
4. Kwiatek-Średzińska K, Kiryłowska M, Uścinowicz M, Daniluk U, Lebensztejn D. The course of acute pancreatitis in children and potential simple laboratory markers of severity – A single Centre retrospective study. Acta Paediatr. 2022;111(11):2229-2234. doi:10.1111/apa.16514
5. Galai T, Cohen S, Yerushalmy-Feler A, Weintraub Y, Moran-Lev H, Amir AZ. Young Age Predicts Acute Pancreatitis Severity in Children. J Pediatr Gastroenterol Nutr. 2019;68(5):720-726. doi:10.1097/MPG.0000000000002294
6. Farrell PR, Jones EK, Hornung L, et al. Cytokine Profile Elevations on Admission Can Determine Risks of Severe Acute Pancreatitis in Children. J Pediatr. 2021;238:33-41.e4. doi:10.1016/j.jpeds.2021.07.015
7. Izquierdo YE, Fonseca EV, Moreno LÁ, Montoya RD, Guerrero Lozano R. Utility of CT classifications to predict unfavorable outcomes in children with acute pancreatitis. Pediatr Radiol. 2018;48(7):954-961. doi:10.1007/s00247-018-4101-4
8. Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018;154(4):1096-1101. doi:10.1053/j.gastro.2018.01.032
9. Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol. 2024;119(3):419-437. doi:10.14309/ajg.0000000000002645
10. Vaughn VM, Shuster D, Rogers MAM, et al. Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic Review. Ann Intern Med. 2017;166(12):883-892. doi:10.7326/M16-2533
11. Bukowski JS, Dembiński Ł, Dziekiewicz M, Banaszkiewicz A. Early Enteral Nutrition in Paediatric Acute Pancreatitis-A Review of Published Studies. Nutrients. 2022;14(16):3441. Published 2022 Aug 22. doi:10.3390/nu14163441
12. Park AJ, Latif SU, Ahmad MU, et al. A comparison of presentation and management trends in acute pancreatitis between infants/toddlers and older children. J Pediatr Gastroenterol Nutr. 2010;51(2):167-170. doi:10.1097/MPG.0b013e3181cea545
13. Dike CR, Lyden E, Quirós-Tejeira RE, Ma J, McCulloh R. Racial/Ethnic Disparities in the Management of Pediatric Acute Pancreatitis Across Children’s Hospitals. J Pediatr Gastroenterol Nutr. 2022;75(5):650-655. doi:10.1097/MPG.0000000000003597

Goal

Listeners will explain the basic pathophysiology, diagnosis, and management of acute pediatric pancreatitis to improve both inpatient care and outpatient counseling. 

Learning Objectives

After listening to this episode listeners will…  

1. Explain the basic pathophysiology of acute pancreatitis.
2. Be familiar with the diagnostic criteria for pancreatitis.
3. Recognize potential causes for acute pancreatitis in children and adolescents.
4. Describe the mainstays of treatment for acute pediatric pancreatitis. 
5. Recall potential complications of acute pancreatitis.

Disclosures

Dr Vitale reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Holloway R, Vitale D, Berk J, Masur S, Chiu C. #139: Behind the Bellyache: Acute Pancreatitis”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ April 23, 2025.