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Pancreatitis in Children: Pathology

by Brian Alverson, MD
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    00:02 In this lecture, we’ll be discussing acute pancreatitis and cholecystitis in children.

    00:09 Let’s start with pancreatitis.

    00:12 So here, you have a 17-year-old male who’s coming in with abdominal pain and vomiting.

    00:18 He admits to drinking alcohol with his friends after school and has been feeling nauseous and vomiting a lot, but was attributing these symptoms to his alcohol use.

    00:28 On physical exam, he has abdominal tenderness, fever, and decreased bowel sounds.

    00:32 You notice he has an upper abdominal pain that radiates up to his back.

    00:37 He’s feeling worse after eating, maybe a half hour to an hour after eating.

    00:42 And then you notice the lab work shows an elevated lipase level.

    00:47 This is a classic case of pancreatitis.

    00:51 Let’s look at what pathologic processes might have led to this problem.

    00:57 So, pancreatitis is an acute or chronic inflammatory process of the pancreas.

    01:02 Generally, in acute disease, it’s a reversible injury associated with inflammation.

    01:08 In chronic disease, there is irreversible destruction from prolonged inflammation.

    01:14 Keep in mind, pancreatitis is much more common in adults and children.

    01:20 But likewise, children are more likely to have acute rather than chronic pancreatitis with the exception of those children with underlying significant systemic disease such as say cystic fibrosis.

    01:35 Metabolic disorders and anatomic or mechanical problems can increase your risk of problems in the pancreas in children.

    01:44 Examples are pancreas divisum, which is a congenital divided pancreas where there might be impairment of drainage of the pancreatic fluid.

    01:56 Choledochal cyst are common in children, and we’ve talked about them in our GI lectures.

    02:03 This choledochal cyst can cause a backup in some cases and a pancreatitis.

    02:10 Or in some cases, patients may have a dysfunction of the Sphincter of Oddi.

    02:15 Remember, that’s the sphincter that might constrict and prevent release of pancreatic juices into the intestinal vault.

    02:23 So, let’s drill down into the pathophysiologic mechanisms of acute pancreatitis.

    02:31 First, a patient may have duct obstruction, a gallstone, for example, that could stack in the common bile duct and prevents exocrine function of that pancreas causing a backup of pancreatic enzymes.

    02:46 Or a patient may ingest a substance such as alcohol, which could cause a direct acinar cell injury so the cells of the pancreas themselves are actually being directly damaged.

    02:59 Or a patient may have some defective intracellular transport of enzymes within the cell that then escape and cause damage.

    03:09 All of these things will lead to an acinar cell injury, and that will result in activated enzymes, which autodigest the pancreas.

    03:21 This is acute pancreatitis.

    03:24 Let’s go through these three major causes one at a time, starting with duct obstruction.

    03:30 The most common cause of duct obstruction is gallstones or biliary sludging.

    03:36 We see this more commonly in patients with sickle cell disease.

    03:39 This is because these patients have a high rate of red blood cell turnover requiring more bilirubin to be excreted, and they can get sludging in their gallbladder.

    03:51 Patients with cystic fibrosis often have pancreatic problems because the chloride channel is defective and they have thicker secretions inside the pancreas.

    04:01 Very rarely in children, there can be neoplasms which might obstruct flow of pancreatic fluids.

    04:09 Choledochal cyst, and there are several types, can involve the pancreas.

    04:14 And so, this cyst may obstruct outflow of pancreatic enzymes.

    04:23 Very rare but you can see especially Ascaris lumbricoides cause obstruction of the pancreatic outflow.

    04:31 And lastly, congenitally, pancreas divisum can cause it as well.

    04:37 All of these causes can result in an interstitial edema within the pancreas, an impaired blood flow and an ischemia to the pancreas, which results in acinar cell injury.

    04:49 Thus, the enzymes that the pancreas is producing become activated.

    04:54 There is an autodigestion of the pancreas resulting in acute pancreatitis.

    05:02 Patients can rarely have direct acinar cell injury that’s not from an obstruction of the pancreatic drainage system.

    05:10 Examples would be alcohol or drugs, direct trauma to the pancreas, an ischemic process in the pancreas.

    05:18 Viruses can rarely cause this.

    05:22 Patients with diabetes because of the autoimmune process occurring in their pancreas may have impairment of exocrine function as well as endocrine function of the pancreas.

    05:33 Also, hypercalcemia is associated with acute pancreatitis.

    05:41 These acinar cell injuries cause release of pro-enzymes resulting in acinar cell injury that further occurs.

    05:50 These enzymes are activated just like in ductal obstruction resulting in the acute pancreatitis.

    06:00 Patients may also have some problems with intracellular transport of some of these digestive enzymes.

    06:07 This happens during metabolic injury through exposure to alcohol, and also as a response to duct obstruction.

    06:14 This further enhances the auto-wide digestion phenomenon.

    06:18 This interruption of delivery of proenzymes to the lysosomal compartment can result in intracellular activation of the enzymes so these cells aren’t essentially eaten from the inside.

    06:31 This acinar cell injury, again, results in activated enzymes and acute pancreatitis.


    About the Lecture

    The lecture Pancreatitis in Children: Pathology by Brian Alverson, MD is from the course Pediatric Gastroenterology.


    Included Quiz Questions

    1. Lipase
    2. Amylase
    3. GGT
    4. AST
    5. ALT
    1. Gallstones
    2. Cystic fibrosis
    3. Choledochal cyst
    4. Neoplasm
    5. Parasite
    1. Children suffer attacks which are more acute.
    2. Children suffer less acute attacks of pancreatitis.
    3. Adults suffer fewer pancreatitis attacks.
    4. Incidence of attack is similar in all ages.
    5. Incidence in children is greater.

    Author of lecture Pancreatitis in Children: Pathology

     Brian Alverson, MD

    Brian Alverson, MD


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