Pediatric Pancreatitis

Acute pancreatitis

  • Etiology:
    — Stones in gallbladder or common bile duct or pancreatic duct
    — Congenital duct anomalies – pancreatic divisum or long common channel
    — Viral (mumps, coxsackie, cytomegalovirus, Epstein Barr virus), medications (L-asparaginase)
    — Blunt abdominal trauma
    — Complication of endoscopy
    — Idiopathic
    — Autoimmune
  • Imaging US:
    — Increased size of the pancreas
    — Decreased pancreatic echogenicity
    — Increased thickness of peripancreatic fat
    — Peripancreatic fluid
  • Imaging CT:
    — Parenchymal findings: Focal or diffuse enlargement of pancreas with heterogenous enhancement or pancreatic necrosis (decreased density, enhancement)
    — Peripancreatic inflammation
    — Peripancreatic fluid
    — Necrosis (pancreatic or peripancreatic)
    — Vascular thrombosis or pseudoaneurysm
    — Pseudocyst (simple fluid, well defined wall, can cross boundaries)
    — Walled off necrosis is pancreatic or peripancreatic and contains debris or solid components
  • Imaging MRI: Abnormal parenchymal signal as normally pancreas is hyperintense to liver on T1WI and isointense to liver on T2WI
  • Imaging of gallstone pancreatitis: Presence of gallstone in distal common bile duct causing pancreatic duct obstruction and elevated pancreatic enzymes
  • Imaging of necrotic pancreatitis:
    — Lack of enhancement of pancreatic parenchyma
    — Necrosis can be pancreatic or peripancreatic
    — Walled-off necrosis is complication that may be diagnosed if collection remains after 4 weeks
  • DDX:
  • Complications: Necrosis of pancreas, peripancreatic fluid, vascular thrombosis or pseudoaneurysm of splenic artery and vein, infection (gas in tissue)
  • Treatment: Large pseudocysts can be drained into stomach
  • Clinical:
    — Presents with abdominal pain and amylase and lipase 3 times normal
    — Complete structural and functional reconstitution of pancreas at end
    — Increasing in incidence due to increasing obesity

Acute recurrent pancreatitis

  • Etiology: Idiopathic, structural anomalies, genetic or heriditary
  • Imaging: Findings are same as acute pancreatitis but look carefully for bilio-pancreatic structural and obstructive causes
  • DDX:
  • Complications:
  • Treatment:
  • Clinical:

Chronic pancreatitis

  • Definition: Greater than 2 episodes of acute pancreatitis that return to baseline
  • Etiology: Cystic fibrosis, fibrosing pancreatitis, heriditary chronic pancreatitis, inborn errors of metabolism
  • Imaging:
    — Main pancreatic duct dilation and irregularity
    — Side pancreatic duct dilation
    — Pancreatic duct strictures
    — Pancreas loss of T1 signal and delayed enhancement
    — Pancreas fibrosis and atrophy
    — Calcification in pancreas
  • DDX:
  • Complications:
  • Treatment:
  • Clinical:
    — Severe chronic abdominal pain
    — Exocrine pancreatic insufficiency
    — Glycemic abnormalities
    — Diabetes

Normal anatomy of pancreatic ducts

  • Minor papilla drains the accessory pancreatic duct (duct of Santorini)
  • Major papilla drains the main pancreatic duct (duct of Wirsung)

Abnormal pancreaticobiliary junction

  • Etiology: Premature union of common bile duct and pancreatic duct outside of duodenal wall leading to long common channel of greater than 15 millimeters
  • Imaging:
    — Hard to see on MRCP
    — There are 3 types
  • DDX:
  • Complications: Can cause pancreatitis when bile duct pressure is greater than pancreatic duct pressure leading to reflux of bile secretions into pancreatic duct
  • Treatment: Bile duct resection and biliary-enteric anastomosis
  • Clinical:
    — Have high association with choledochal cyst (90-100%)
    — Is risk factor for biliary malignancy

Radiology Cases of Acute Pancreatitis

Radiology Cases of Chronic Pancreatitis

AXR of cystic fibrosis with pancreatic insufficiency
AXR shows calcifications throughout the pancreas.
US of pancreatitis caused by pancreatic duct stone
Transverse US of the pancreatic head (above) shows just to the right of midline a round echogenic lesion with posterior shadowing in the center of the pancreatic head while transverse US of the pancreatic body (below) shows a dilated pancreatic duct throughout the body of the pancreas.

Radiology Cases of Acute Pancreatitis and Chronic Pancreatitis

Radiology Cases of Acute Pancreatitis With Pseudocyst and Chronic Pancreatitis Due to Cystic Fibrosis and Fatty Infiltration of Liver and Normal Appendix and Distal Intestinal Obstruction Syndrome

CT of enlarged but normal appendix in cystic fibrosis
Axial CT with contrast of the abdomen (above left) shows a low density liver due to fatty infiltration and a low density pancreas with calcifications that has a round low density fluid collection near the pancreatic head. The appendix in the right lower quadrant posterior to the cecum is dilated in diameter up to 10 mm but has no periappendiceal inflammation (above right and below). There is stool mixed with air in the terminal ileum medial to the cecum (above right and below).