*2.3.1 Clinical features*

There are differences in clinical onset and natural course between adults and children. Acute pancreatitis symptoms are non-specific and depend on child's age and developmental level. Abdominal pain is typically epigastric but it can be localized to the right upper quadrant or left upper one. It can occur constantly or intermittently, with radiation to the back. The pain is dull, boring and deep. Pancreatitis should be suspected in all pediatric patients who experience, as isolated or combined symptoms, abdominal pain, nausea and/or vomit, the latter due to peripancreatic inflammation extended to the gastric wall [8].

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

ides and blood cell count [10].

*2.3.3 Diagnostic imaging*

The increased serum levels of amylase enzyme greater than three upper limits

Transabdominal ultrasound is the diagnostic study of choice to evaluate biliary tree abnormalities in children. In pediatric age pancreatic head tend to be larger than body and tail and this is a potentially confounding feature that may lead to a misdiagnosis. Diffuse or focal enlargement of the pancreatic gland may be present in AP and is attributable to edema. Echogenicity is a variable feature in case of

One of the most valid radiological finding is represented by the dilatation of the pancreatic duct (1–6 years old, >1.5 mm; 7–12 years old, >1.9 mm; 13–18 years, >2.2 mm). Poorly defined borders or localized intraparenchymal fluid collection are

Parenchymal hypodensities, heterogeneity, irregularity of the glandular margins and inflammatory changes in the peripancreatic fat could be seen at CT (computed tomography) scans. The use of intravenous contrast is mandatory to evaluate different grades of glandular involvement and patency of adjacent vessels. Furthermore, CT imaging may show the extent of peripancreatic or intraparenchymal fluid

Magnetic resonance cholangiopancreatography (MRCP) is challenging o perform in pediatric patients and needs to be tailored to different body sizes. The pancreatic glands become heterogeneous and hypointense on T1-weighted images

Commonly used scoring systems (Ranson, modified Glasgow and pediatric acute pancreatitis severity) have demonstrated limited ability to predict disease severity in children and adolescents with acute pancreatitis. The sensitivity and negative predictive value of the above scores are insufficient to guide decision making in pediatric patients. Therefore better methods are needed for risk stratification. Anyway, in a logistic regression model [12], only white blood cell count at admission more than 18,500/mcL, trough calcium less than 8.3 mg/dL and blood urea nitrogen greater than 5 mg/dL appear to correspond independently with a poor outcome. The lack of an accurate scoring system could cause delays in appropriate clinical management and increase the risk of progressive life-threatening complications. In recent years Suzuki [13] has investigated a modified score that reflects pediatric SIRS (systemic inflammatory response syndrome) score, age and weight (**Figure 3**) and it has proved a more adequate scoring system in children, helping to improve

pediatric pancreatitis, however hypoechogenicity is frequently seen.

usually detected at ultrasound imaging in the acute setting.

collections and the presence abscessualization.

in the early stages of inflammation [11].

treatment outcome in these patients.

*2.3.4 Severity assessment*

of normal are also detected in case of pancreatobiliary tract obstruction and perforative peritonitis, in addition to salivary gland pathologies and renal failure. Therefore this parameter is associated with a low specificity. On the other hand serum lipase levels have a sensitivity of 86.5–100% and specificity of 84.7–99.0%. In case of severe pancreatitis, serum lipase levels seven times higher than normal have been detected within the first 24 h. It is important to underline that in case of drug-induced acute pancreatitis serum amylase may not be elevate [9]. In addition, we may consider other chemistry panels to define a diagnosis like serum calcium, electrolytes, urea nitrogen, creatinine, transaminases, albumin, bilirubin, triglycer-

*2.3.2 Biochemical tests*

**Figure 2.**

*Pediatric acute pancreatitis diagnostic flow chart.*

## *2.3.2 Biochemical tests*

*Pancreatitis*

**2.3 Diagnosis**

*2.3.1 Clinical features*

The diagnosis of AP in children depends on clinical manifestations, laboratory tests, and imaging. Moreover a careful estimation of severity is fundamental for

There are differences in clinical onset and natural course between adults and children. Acute pancreatitis symptoms are non-specific and depend on child's age and developmental level. Abdominal pain is typically epigastric but it can be localized to the right upper quadrant or left upper one. It can occur constantly or intermittently, with radiation to the back. The pain is dull, boring and deep. Pancreatitis should be suspected in all pediatric patients who experience, as isolated or combined symptoms, abdominal pain, nausea and/or vomit, the latter due to

establish the most appropriate treatment (**Figure 2**).

peripancreatic inflammation extended to the gastric wall [8].

**70**

**Figure 2.**

*Pediatric acute pancreatitis diagnostic flow chart.*

The increased serum levels of amylase enzyme greater than three upper limits of normal are also detected in case of pancreatobiliary tract obstruction and perforative peritonitis, in addition to salivary gland pathologies and renal failure. Therefore this parameter is associated with a low specificity. On the other hand serum lipase levels have a sensitivity of 86.5–100% and specificity of 84.7–99.0%. In case of severe pancreatitis, serum lipase levels seven times higher than normal have been detected within the first 24 h. It is important to underline that in case of drug-induced acute pancreatitis serum amylase may not be elevate [9]. In addition, we may consider other chemistry panels to define a diagnosis like serum calcium, electrolytes, urea nitrogen, creatinine, transaminases, albumin, bilirubin, triglycerides and blood cell count [10].

## *2.3.3 Diagnostic imaging*

Transabdominal ultrasound is the diagnostic study of choice to evaluate biliary tree abnormalities in children. In pediatric age pancreatic head tend to be larger than body and tail and this is a potentially confounding feature that may lead to a misdiagnosis. Diffuse or focal enlargement of the pancreatic gland may be present in AP and is attributable to edema. Echogenicity is a variable feature in case of pediatric pancreatitis, however hypoechogenicity is frequently seen.

One of the most valid radiological finding is represented by the dilatation of the pancreatic duct (1–6 years old, >1.5 mm; 7–12 years old, >1.9 mm; 13–18 years, >2.2 mm). Poorly defined borders or localized intraparenchymal fluid collection are usually detected at ultrasound imaging in the acute setting.

Parenchymal hypodensities, heterogeneity, irregularity of the glandular margins and inflammatory changes in the peripancreatic fat could be seen at CT (computed tomography) scans. The use of intravenous contrast is mandatory to evaluate different grades of glandular involvement and patency of adjacent vessels. Furthermore, CT imaging may show the extent of peripancreatic or intraparenchymal fluid collections and the presence abscessualization.

Magnetic resonance cholangiopancreatography (MRCP) is challenging o perform in pediatric patients and needs to be tailored to different body sizes. The pancreatic glands become heterogeneous and hypointense on T1-weighted images in the early stages of inflammation [11].
