*4.3.2 Pancreatic function tests*

Altered pancreatic function tests are diagnostic of chronic pancreatitis but also are detected in case of other clinical conditions such as pancreatic agenesis or resection, intestinal atrophy, kwashiorkor and gastrinoma. We also have to consider mild or moderate forms of chronic pancreatitis in case of normal tests. Exocrine pancreatic function can be assessed by direct or indirect evaluations. Direct tests pancreatic such as the secretin-cholecystokinin test have the highest sensitivity and specificity but at the same time they are inadequate for routine clinical practice in pediatric population. On the other hand indirect tests are noninvasive and routinely used. Indirect pancreatic function test can be divided in three main groups:


Fecal elastase-1 (FE1) is the most sensitive test in the evaluation of exocrine pancreatic function in chronic pancreatitis [25].

Fecal elastase-1 is a proteolytic pancreatic enzyme that is not degraded during its passage through the gastrointestinal tract. Analysis of FE1 is simple and practical to be managed but it may be compromised in case of diarrhea, with an associated risk of falsely low FE1 concentration [26].

## *4.3.3 Biopsy*

A pancreatic EUS-guided biopsy may represent the gold standard for the diagnosis of chronic pancreatitis but it is not widely available.

And besides some etiologies of chronic pancreatitis, such as autoimmune or hereditary pancreatitis, need multiple biopsies to be diagnostic. At histological examination irregular fibrosis can be seen while intralobular fibrosis alone is not specific for chronic pancreatitis [22].

### **4.4 Treatment**

Both the stage and etiology of CP influence its management. With disease progression, chronic pain management and treatment of pancreatic insufficiency or diabetes are required. Acetaminophen may be effective in the early stages, but therapy generally advances to narcotics. Pancreatic enzyme supplements and antioxidant therapy (selenium, ascorbic acid, b-carotene, a-tocopherol, and methionine) are prescribed frequently in this setting. Endoscopic treatment for CP should be considered only when ductal strictures or pancreatic duct calculi are present or for symptomatic pseudocysts. Surgical treatment is still indicated in selected patients when conservative treatment failed. Localized disease can be treated with partial pancreatic resection (i.e., in case of a pancreatic inflammatory head mass)

**79**

*Pediatric Pancreatitis: Not a Rare Entity DOI: http://dx.doi.org/10.5772/intechopen.85370*

function and maintain weight gain.

must be accepted by families.

**5. Conclusions**

patients.

while radical pancreatectomy with islet cell autotransplant is currently offered to patients who have genetic causes of pancreatitis (as we'll describe in the next section). A longitudinal pancreaticojejunostomy (known as modified Puestow procedure) can be definitely avoided. Although many patients have pain relief, a number of patients continue to have pain. In up to 20% of adults, the pain is as intense as it was before the resection. Preadolescents are more likely to be insulin-independent than older children and adults. Thus time to surgical procedure is fundamental to avoid a progressive decrease in islet cell yield. Pancreatic insufficiency is treated with pancreatic enzyme replacement therapy. The final goal is to restore digestive

Children with chronic pancreatitis who suffer recurrent severe episodes of abdominal pain, chronic use of analgesics (opioids) and frequent hospitalizations may benefit from TPIAT, in order to improve their quality of life. A multidisciplinary team including gastroenterologists, endocrinologists, surgeons, anesthesiologists, psychologists, radiologists and nutritionists guides the selection of these

Thus the procedure consists in a demolitive operative phase, followed by a reconstructive one that includes an hepaticojejunostomy plus gastrojejunostomy or a duodenojejunostomy and the autotransplantation of islets via the portal vein. Osmotic, mechanical or hypoxia damage of islets should be considered, especially in the pre-engraftment phase and the risk of developing diabetes mellitus

Anyway pain resolution, independence from analgesics and significant improvement in quality of life has been reported in the majority of children with CP follow-

The incidence of acute pancreatitis is increasing in children and it should be considered as part of differential diagnosis in case of abdominal pain. The etiology of acute pancreatitis in this subpopulation is related to several conditions and risk factors, such as drugs, obesity, infections, trauma and anatomic abnormalities but

Rapid and accurate assessment of severity is useful for selecting an appropriate initial treatment and predicting the prognosis. The International Study Group for Pediatric Pancreatitis: In Search for a Cure (INSPPIRE) focused on ARP and CP in pediatrics and we can delineate more accurately clinical presentations, risk factors and natural history of pediatric pancreatitis to define a more appropriate therapeu-

ing TPIAT, and glycemic control is managed without difficulty [24, 27].

genetic predisposition represents the master causative factor.

tic strategy, often considering that a children is not a small adult.

*4.4.1 Total pancreatectomy with islet autotransplantation (TPIAT)*

#### *Pediatric Pancreatitis: Not a Rare Entity DOI: http://dx.doi.org/10.5772/intechopen.85370*

*Pancreatitis*

removal or stricture dilation [23].

*4.3.2 Pancreatic function tests*

To reduce the exposure to ionizing radiation MRI/MRCP and ultrasound (US) are preferred. ERCP, as in adults, can be considered for procedures such as stone

Altered pancreatic function tests are diagnostic of chronic pancreatitis but also are detected in case of other clinical conditions such as pancreatic agenesis or resection, intestinal atrophy, kwashiorkor and gastrinoma. We also have to consider mild or moderate forms of chronic pancreatitis in case of normal tests. Exocrine pancreatic function can be assessed by direct or indirect evaluations. Direct tests pancreatic such as the secretin-cholecystokinin test have the highest sensitivity and specificity but at the same time they are inadequate for routine clinical practice in pediatric population. On the other hand indirect tests are noninvasive and routinely

used. Indirect pancreatic function test can be divided in three main groups:

in urine and serum (NBT-PABA test, pancreolauryl test);

excretion and fecal fat concentration);

pancreatic function in chronic pancreatitis [25].

nosis of chronic pancreatitis but it is not widely available.

of falsely low FE1 concentration [26].

specific for chronic pancreatitis [22].

*4.3.3 Biopsy*

**4.4 Treatment**

1.Analysis of the hydrolyzed products of pancreatic enzymes' activity detectable

2.Assessment of undigested and unabsorbed food components in feces (fecal fat

3.Dosage of pancreatic enzymes in the serum (amylase, isoamylase, lipase, trypsinogen, elastase-1) or stool (chymotrypsin, lipase, elastase-1).

Fecal elastase-1 (FE1) is the most sensitive test in the evaluation of exocrine

Fecal elastase-1 is a proteolytic pancreatic enzyme that is not degraded during its passage through the gastrointestinal tract. Analysis of FE1 is simple and practical to be managed but it may be compromised in case of diarrhea, with an associated risk

A pancreatic EUS-guided biopsy may represent the gold standard for the diag-

And besides some etiologies of chronic pancreatitis, such as autoimmune or hereditary pancreatitis, need multiple biopsies to be diagnostic. At histological examination irregular fibrosis can be seen while intralobular fibrosis alone is not

Both the stage and etiology of CP influence its management. With disease progression, chronic pain management and treatment of pancreatic insufficiency or diabetes are required. Acetaminophen may be effective in the early stages, but therapy generally advances to narcotics. Pancreatic enzyme supplements and antioxidant therapy (selenium, ascorbic acid, b-carotene, a-tocopherol, and methionine) are prescribed frequently in this setting. Endoscopic treatment for CP should be considered only when ductal strictures or pancreatic duct calculi are present or for symptomatic pseudocysts. Surgical treatment is still indicated in selected patients when conservative treatment failed. Localized disease can be treated with partial pancreatic resection (i.e., in case of a pancreatic inflammatory head mass)

**78**

while radical pancreatectomy with islet cell autotransplant is currently offered to patients who have genetic causes of pancreatitis (as we'll describe in the next section). A longitudinal pancreaticojejunostomy (known as modified Puestow procedure) can be definitely avoided. Although many patients have pain relief, a number of patients continue to have pain. In up to 20% of adults, the pain is as intense as it was before the resection. Preadolescents are more likely to be insulin-independent than older children and adults. Thus time to surgical procedure is fundamental to avoid a progressive decrease in islet cell yield. Pancreatic insufficiency is treated with pancreatic enzyme replacement therapy. The final goal is to restore digestive function and maintain weight gain.
