How Do I Choose the Best Chronic Pancreatitis Treatment?

Chronic pancreatitis in children refers to local or diffuse chronic and progressive inflammation of the pancreas. The disease is progressive, persistent, and irreversible. Increasing pancreatic parenchymal damage, leading to progressive decline of pancreatic endocrine and exocrine functions.

Basic Information

Visiting department

Pediatrics, Gastroenterology

Common locations

pancreas

Common causes

Caused by heredity, malnutrition, consumption of tapioca flour, abdominal trauma, etc.

Common symptoms

Abdominal pain, malabsorption and stunting, diabetes, pancreatic tumors, etc.

Causes of chronic pancreatitis in children

Chronic calcifying pancreatitis

(1) Hereditary pancreatitis is an autosomal recessive genetic disease. The gene for hereditary pancreatitis is located on the long arm of chromosome 7. Arginine at position 117 of trypsinogen is replaced by histidine, causing the pancreas to self-digest and induce pancreatitis.

(2) Adolescent tropical (nutritive) pancreatitis is a more common cause of childhood. It is found in some people in South India, Indonesia, and tropical regions near the equator of Africa with insufficient nutrition intake. The cause is malnutrition and consumption of cassava flour. Cassava contains toxic glycosides.

2. Chronic obstructive pancreatitis

(1) Pancreatic schizophrenia Pancreatic schizophrenia is the most common malformation of the pancreas with an incidence of 5% to 15% in the general population. Because the dorsal and ventral pancreatic primordium cannot be fused, pancreatic tail, pancreatic body and part of pancreatic head are drained through the relatively narrow parapancreatic duct instead of the main pancreatic duct.

(2) Abdominal trauma After trauma to the abdomen, hidden damage to the pancreatic ducts can lead to stenosis, pseudocyst formation, and chronic obstruction.

3. Idiopathic fibrotic pancreatitis

Idiopathic fibrotic pancreatitis is rare and may have abdominal pain or obstructive jaundice. Glands showed diffuse fibrous tissue hyperplasia.

4. Other

Pancreatitis can occur in children with hyperlipidemia type I, IV, and V. Transient hyperlipidemia can occur during pancreatitis, so the blood lipid elevation in acute pancreatitis must be re-measured after improvement. Other causes include gallbladder fibrosis, sclerosing cholangitis, and inflammatory bowel disease.

Clinical manifestations of chronic pancreatitis in children

Abdominal pain

Most children with chronic pancreatitis have intermittent or chronic abdominal pain, the cause of which is not very clear, mainly in the upper abdomen, quarter ribs or around the umbilicus, back pain, vomiting and fever are not common. Sometimes the pain can last for weeks. The degree of pain is different, but as the disease progresses, the pain can be gradually reduced, and some children can even be completely relieved.

2. Absorption disorders and stunting

Mainly due to post-prandial abdominal pain, which restricts dietary intake and makes nutritional supply inadequate. In addition, poor pancreatic function affects fat and protein absorption. Lipid diarrhea is more than protein diarrhea, because the reduction of lipase is significantly more than that of protease in the early stage of the disease. Despite severe fatty diarrhea, fat-soluble vitamin malabsorption is rare, and only vitamin B ₁₂ malabsorption is more pronounced. Both blood lipids and urine amino acids were increased.

3. Diabetes

Abnormal glucose metabolism is due to impaired release of insulin and glucagon, which can sometimes occur early in the disease. Diabetes is the most common clinical manifestation of tropical pancreatitis in adolescents. It is also seen in calcified pancreatitis and alcoholic pancreatitis. Insulin secretion decreases due to islet cell damage, and fibrosis around the islets causes circulation disturbances, which reduces insulin release into the blood.

4. Malignant tumor of the pancreas

For some children, the incidence of pancreatic cancer has increased significantly. The level of this risk varies with the cause, and it may also be a natural outcome of chronic pancreatitis in some children. To date, there have been no reports of pancreatic malignancies in children with hereditary pancreatitis.

5. Other

Chronic pancreatitis in children with ascites is rare, and pleural effusion is even rarer. In some cases, pancreatic enzymes escape into the bloodstream and enter the skin, leading to necrosis of the subcutaneous adipose tissue, forming erythema and nodules. Some children may have an abdominal mass, which may be an inflammatory mass of the pancreas, or it may be a pseudocyst or a benign or malignant tumor of the pancreas.

Pediatric chronic pancreatitis examination

1. General laboratory inspection

(1) Serum amylase can be elevated during acute episodes, but serum amylase does not increase in most cases due to the secretion of pancreatic juice.

(2) A large amount of fat droplets and undigested muscle fibers were detected by stool microscopy.

(3) The urine glucose response and glucose tolerance test were positive in some cases.

2. Pancreas exocrine function test

(1) The trypsin-secretin test (PS test) is a method for directly examining the secretory function of the pancreas when chronic pancreatitis is less severe. Children with this disease may have pancreatic juice outflow, bicarbonate, and pancreatic enzyme excretion below normal values after administration of tryptase or secretin.

(2) Benzoyl-tyrosyl-p-aminobenzoic acid test This test is more accurate in the advanced stage (sensitivity is about 70%), but it is less sensitive in early or mild chronic pancreatitis, and in hepatobiliary diseases, Kidney disease and small bowel disease can be false positives.

3. Imaging examination

(1) Plain radiographs of the pancreas show pancreatic calcification or pancreatic duct stones.

(2) Ultrasound of the pancreas. Pancreatic calcification, pancreatic duct stones, pancreatic duct dilatation, localized or diffuse enlargement or atrophy of the pancreas, and pseudopancreatic cysts can be seen.

(3) CT scan shows irregular outline of pancreas, pancreatic calcifications, dilated or irregular pancreatic ducts, and glandular atrophy.

(4) Endoscopic retrograde cholangiopancreatography (ERCP) Pancreatography shows a dilated or irregular bead-like lumen, with calcifications or stones, and pseudocysts.

(5) Pancreatic angiography The segmental stenosis or occlusion or aneurysm of the internal pancreatic artery can be seen through the spleen artery or upper duodenal mesenteric angiography, and the internal pancreatic vein can also be narrowed or occluded.

Diagnosis of chronic pancreatitis in children

According to the child's typical history of pancreatitis and chronic signs in imaging, chronic pancreatitis in children is easy to diagnose. More typical are children with recurrent abdominal pain, vomiting, and elevated serum amylase. Some children have malabsorption and growth disorders. Deficiency of fat-soluble vitamins is rare.

Differential diagnosis of chronic pancreatitis in children

It is distinguished from other causes such as steatosis, diabetes, upper abdominal mass, and jaundice.

Pediatric chronic pancreatitis treatment

The main purpose of treatment is to reduce symptoms and control complications.

Symptomatic treatment

(1) Abdominal pain During the onset of pain, the treatment method is similar to the treatment of acute pancreatitis. It is important for children with chronic pancreatitis to control pain, but sometimes it is difficult. You can use steroidal or non-steroidal anti-inflammatory drugs; trypsin supplementation to inhibit cholecystokinin secretion. In the intermittent period, the child has no obvious pain and can only be treated symptomatically.

(2) Pseudocysts Small pseudocysts usually disappear on their own, or they can persist for a long time without symptoms. If the cyst is large and there is still no tendency to shrink for more than 6 weeks, drainage treatment should be performed. There are a variety of drainage methods, which can be punctured and drained under the guidance of B ultrasound or CT, or surgical drainage.

(3) Diabetes Chronic pancreatitis in children with diabetes is usually mild, and ketoacidosis is rare. If the urine sugar content is high, treatment is needed, and a relatively small dose of insulin is needed to maintain blood glucose levels.

2. Diet therapy

Malabsorption is common in children with chronic pancreatitis, but the incidence in children is unknown. Treatment with trypsin preparations requires a balanced diet supplemented with vitamins. The purpose of diet therapy is to reduce symptoms and improve the general condition of the child. Appropriate restriction of fat intake can reduce pain and fatty diarrhea in children. But while considering reducing symptoms, you must pay attention to providing sufficient calories and protein for child development. A small, frequent diet is desirable for some children.

3. Surgical treatment

Chronic pancreatitis in children is mostly treated by medical treatment. Children with the following indications can be treated surgically:

(1) Uncontrollable chronic abdominal pain.

(2) Common bile duct obstruction.

(3) Pancreatic duct obstruction and expansion.

(4) Pseudocysts and their complications.

For biliary and pancreatic duct obstruction, endoscopic retrograde cholangiopancreatography (ERCP) can be used for diagnosis first. After the diagnosis is confirmed, nasal bile duct drainage and sphincterotomy can be used for treatment. If the pain is reduced after ERCP treatment, further surgical methods can be used, and the drainage effect will be better. For stone obstruction of common bile duct and pancreatic duct, if the stone can be removed by surgery, the treatment effect is the best. For non-lithic obstruction of the bile duct and pancreatic duct, sphincterotomy or shaping is commonly used, or bile duct intestinal anastomosis or pancreatic duct anastomosis is used to remove part of the pancreas. It is often used for localized lesions of the pancreatic body and tail. Ductectomy is used for lesions of the pancreatic head. For severe persistent abdominal pain, the pancreas can be completely removed at one time, but the pancreatic exocrine and endocrine functions may be insufficient after surgery. It has a certain effect on pancreas transplantation in children with complete loss of pancreatic function.

Prognosis of chronic pancreatitis in children

Active treatment can relieve symptoms, but it is not easy to cure. Most patients with advanced disease die from complications, and very few people can develop pancreatic cancer.

Prevention of chronic pancreatitis in children

Hereditary chronic recurrent pancreatitis should be consulted for genetic diseases; tropical pancreatitis in adolescents should prevent protein malnutrition and balance the diet; prevent hyperlipidemia and hypercalcemia; prevent vitamin D poisoning and excessive nutrition; Thoroughly treat acute pancreatitis and prevent disease progression.