develop bowel ischemia, perforation, and bleeding Significant GI bleeding is rare, but possible Gastrointestinal Vascular Malformations GI vascular malformations are rare causes of GI bleeding in children and may be seen as a part of a congenital syndrome, such as Klippel–Trenaunay–Weber syndrome or blue rubber bleb nebus syndrome Lesions may be solitary or diffuse Infantile hemangiomas may also occur in the GI tract and present with bleeding Acute hemorrhage is possible, however less likely than slow, chronic blood loss ED management of patients with GI bleeding from vascular malformations is the same as for any patient with potentially significant blood loss After initial stabilization, referral to an appropriate subspecialty consultation for definitive diagnosis and definitive treatment is warranted Foreign Bodies Swallowed foreign bodies can cause significant trauma and GI bleeding Eighty percent to 90% of ingested foreign bodies are able to pass without intervention, even those with sharp edges ( Fig 91.2 ) Approximately 10% to 20% must be removed endoscopically, and only approximately 1% requires surgery Removal by endoscopy is indicated if significant bleeding occurs or if the foreign body is retained in the esophagus Consideration for endoscopic and/or surgical removal should be made if the foreign body is causing symptoms (e.g., obstruction), involves multiple magnets, or is greater than cm in length (see Chapter 32 Foreign Body: Ingestion and Aspiration ) PANCREATITIS Goals of Treatment Pancreatitis can be difficult to diagnose in children and is often overlooked as it is uncommon and no specific pathognomonic symptoms are associated with the condition The goal of ED management is to make an early diagnosis, recognize any potential causative factors, and address any complications that may be present at the time of presentation Once identified, the goals of medical treatment include fluid resuscitation, pain control, and treatment of early complications such as hypovolemia, hypocalcemia, respiratory distress, and infection CLINICAL PEARLS AND PITFALLS One-third of acute pancreatitis cases will develop into severe acute pancreatitis Aggressive fluid management with crystalloid fluids is associated with improved outcomes Mild trauma from small pointed objects, such as sticks, handlebars, or fence posts, may transmit injury directly to the pancreas Serum amylase and lipase levels may not correlate with severity of disease There is no indication for empiric antibiotics unless necrosis or infection is suspected Current Evidence Pancreatitis occurs in approximately 1/10,000 children per year, and the incidence has been increasing in recent years It can be caused by anatomic abnormalities, obstructive or biliary disease, infectious etiologies, trauma, toxins, genetic or inborn errors of metabolism or systemic disease In infants and toddlers, pancreatitis is most commonly associated with multisystem disease such as HUS or pulmonary disease In older children and adolescents, the most common cause of pancreatitis remains unknown or “idiopathic” followed closely by trauma and structural disease Table 91.3 lists the causes of pancreatitis Regardless of the initiating event, acute pancreatitis results in the activation of the numerous pancreatic enzymes, including proteolytic enzymes, lipase, amylase, elastase, and phospholipase A, which causes autodigestion of the gland The process may be focal or diffuse Mild disease, or acute edematous pancreatitis, is by far the most common form seen in children, is usually self-limited, and associated with complete recovery Necrotic or hemorrhagic pancreatitis occurs when the autodigestive process intensifies with increased inflammation, fat necrosis, and hemorrhagic changes It is associated with significant morbidity and mortality, with the mortality rate approaching 10% Complications from severe pancreatitis include pseudocyst formation, necrosis, secondary bacterial infections, acute respiratory distress syndrome, shock, multiorgan system failure, and death Early in the disease it is difficult to predict which patients are at risk for severe disease and a poor prognosis There are several well-validated scoring systems in adults, including the Modified Glasgow score, Ranson criteria, and APACHE II, however they have been shown to be poor predictors of outcome in children Recent studies in children have attempted to better classify the disease in children Clinical Considerations Clinical Recognition The majority of children with acute pancreatitis initially present with nonspecific signs and symptoms Abdominal pain (87%) and vomiting (64%) are the most common presenting symptoms The character of the abdominal pain may range from tolerable discomfort to severe pain Classically, the pain is constant and localized to the epigastrium and may radiate to the back (left or right scapula) or to the right or left upper quadrants The pain is classically described as knifelike in quality and is aggravated when the patient lies supine Vomiting may be severe and protracted Fever, abdominal distention, and jaundice may also be present In cases of severe necrotic pancreatitis, patients may complain of dizziness or present with hypotension and shock Mental status changes including psychosis and coma are common in necrotic pancreatitis