Paediatric necrotizing pancreatitis

Abstract

A 13-year-old boy was admitted with a 7-week history of worsening epigastric pain and vomiting. There was no prior history of similar episodes, jaundice or viral infection. There was no family history of hyperlipidaemia. His only comorbidity was obesity with a body mass index of 36.6 kg/m2. On examination he was tachycardic and tachypnoeic with a tender epigastrium. Blood results showed a leucocytosis, normal liver function tests and normal cholesterol, C-reactive protein and amylase levels. An ultrasound scan was performed but did not reveal any detail because of his body habitus. A computed tomography scan showed a necrotic pancreas and that gallstones were present. The patient deteriorated, becoming increasingly septic, and was transferred across to a paediatric intensive care unit. Initial management consisted of fluid resuscitation, intravenous protein pump inhibitors, intravenous antibiotics, parenteral nutrition and surgical review. He initially responded to treatment, but then deteriorated with worsening sepsis requiring readmission to the paediatric intensive care unit. The repeat computed tomography scan (Figure 1) revealed bilateral pleural effusions, free fluid in the abdomen and peripancreatic inflammation. He showed signs of abdominal compartment syndrome and was taken to theatre for a laparotomy. The operative findings were a necrotic pancreas with over 5 litres of free fluid. A pancreatic necrosectomy and laparostomy was performed (Figure 2). Between 60 and 70% of his pancreas was involved and removed. The rest of his postoperative course was uneventful. He was discharged on Creon supplements, insulin and an antihypertensive. His weight had dropped from 106 kg on admission to 84 kg. After further surgical and paediatric review as an outpatient he later underwent an open cholecystectomy with an ontable cholangiogram.