FIGURE 91.2 A, B: Gastric foreign body A 9-year-old female accidentally ingested a 2.7cm nail when hanging stockings and was holding nail in her mouth TABLE 91.3 CAUSES OF ACUTE PANCREATITIS IN CHILDREN Trauma: blunt, penetrating, surgical Infectious: mumps, coxsackievirus B infection, hemolytic Streptococcus infection, Salmonella infection, hepatitis A and B Obstructive: cholelithiasis, ascaris infection, congenital duodenal stenosis, duplications, tumor, choledochal cyst Drugs: steroids, chlorothiazides, salicylazosulfapyridine, azathioprine, alcohol, valproic acid, tetracyclines, borates, oral contraceptives Systemic: systemic lupus erythematosus, periarteritis nodosa, malnutrition, peptic ulcer, uremia Endocrine: hyperparathyroidism Metabolic: hypercholesterolemia, cystic fibrosis, vitamin A and D deficiency Hereditary Idiopathic Triage Considerations Most patients with pancreatitis present with nonspecific signs and symptoms and are hemodynamically stable A minority of patients, especially those with necrotic or hemorrhagic disease may present in shock or jaundice These patients require immediate recognition and appropriate stabilization Clinical Assessment The abdomen may be distended but is usually not rigid, and the patient may prefer sitting or lying on their side with knees flexed There may be mild to moderate voluntary guarding in the epigastrium A palpable epigastric mass suggests pseudocyst Ascites is rare Bowel sounds may be decreased or absent Associated physical findings may include signs of parotitis, mild hepatosplenomegaly, epigastric mass, pleural effusions, and mild icterus Although rare, rebound tenderness or a rigid abdomen is a poor prognostic sign Similarly, a bluish discoloration around the umbilicus (Cullen sign) or flanks (Grey Turner sign) is rare in children but portends a poor prognosis and suggests a diagnosis of hemorrhagic pancreatitis Signs of overt hemodynamic instability are rarely evident at initial presentation It is particularly important to evaluate patients for clinical signs of hypocalcemia (Trousseau and Chvostek signs) Jaundice may suggest distal biliary obstruction Diagnostic criteria have recently been updated and require two out of the three following criteria: (1) abdominal pain compatible with acute pancreatitis, (2) serum amylase and/or lipase three times greater than the upper limits of normal, and (3) imaging consistent with acute pancreatitis While lipase is thought to be more sensitive and specific, both serum amylase and lipase can be used in the diagnosis of acute pancreatitis Serum lipase levels typically begin to rise within hours of symptom onset and peak around 24 to 30 hours The lipase level remains elevated longer than amylase and may remain elevated for more than week Other causes for elevated serum amylase and lipase levels include liver failure, trauma or hepatitis, renal failure, intestinal inflammation such as celiac or inflammatory bowel disease, intestinal obstruction or infarction, penetrating or perforated ulcer, pneumonia, acute biliary tract disease, salpingitis, salivary adenitis, diabetic ketoacidosis, and benign macroamylase or macrolipase Ultrasound should be considered first line imaging in cases of pancreatitis While it may not be necessary for diagnosis in patients with a clear presentation and elevated laboratory findings, it can be useful in cases where the diagnosis is less clear It is also useful for the evaluation of complications (necrosis or pseudocyst) or to evaluate for causative etiologies such as gallstones Abdominal CT scan and MRI/MRCP should be reserved for more complicated cases Endoscopic retrograde cholangiopancreatography (ERCP) is most often used when pancreatitis is caused by biliary obstruction It may also be useful in evaluating for the presence and severity of pancreatitis complications Management Medical management of acute pancreatitis in the ED consists mostly of IV fluid administration and pain control Aggressive fluid management has been associated with improved outcomes in children The progression of pancreatitis from mild to severe disease is thought to be associated with poor local pancreatic circulation So early fluid administration not only corrects hypovolemia and restores circulating volume, but also improves local perfusion within the pancreas On arrival to the ED, IV fluids should be started immediately, and the patient’s oral intake should be discontinued Once the acute shock episode is resolved, IV fluids should be administered at 1.5 to times the maintenance rate for the first 24 hours Crystalloids are the preferred fluid, however there is a lack of data comparing normal saline and lactated Ringer’s Vital signs and urine output should be monitored frequently A crucial part of management is the treatment of abdominal pain There is no strong evidence regarding the choice of pharmacologic agent for pain control For mild to moderate pain, nonopiates may be useful, including NSAIDs For more severe pain, opiates may be utilized safely Historically there was a theoretical concern about sphincter of Oddi spasm with the use of various opiates, however this has not been supported in the literature The use of anticholinergic or H2 -receptor antagonists to reduce gastric secretion is not recommended in the initial management of patients Laboratory studies that should be performed in the ED in patients with severe disease should include amylase, lipase, CBC count, electrolytes, BUN, calcium, glucose, AST, ALT, bilirubin (direct and indirect), alkaline phosphatase, serum gamma-glutamyltransferase (GGT), triglyceride, PT, and PTT A chest radiograph should be obtained and evaluated for pleural effusion, interstitial pneumonic infiltrates, and basilar atelectasis A flat and upright abdominal radiograph can assist in evaluating for perforation, ascites, and pancreatic calcifications An abdominal ultrasound should be performed Antibiotics are not routinely indicated in the initial management of pancreatitis; however, infection is very common with necrotizing pancreatitis and is associated with morbidity and mortality Pancreatic abscess or superinfection should be considered if the patients present with fever and in those cases, broad-spectrum antibiotic coverage is indicated While medical management is sufficient for most children with pancreatitis, surgical consultation is indicated in cases of traumatic pancreatitis, necrosis, prolonged or potentially superinfected pseudocysts, or biliary duct obstruction from stones or anatomic abnormalities such as choledochal cysts Clinical Indications for Admission All patients with acute pancreatitis should be admitted to the hospital The decision to admit to the ICU should be based on hemodynamic status and concern for complications BILIARY TRACT DISEASE Biliary Atresia Goals of Treatment BA is uncommon but is associated with very high morbidity and mortality, and is a leading cause of liver transplant in young children Early detection, before 30 to 45 days of life, can significantly improve patient outcomes and potentially avoid transplantation In the United States, the average age of diagnosis unfortunately remains at approximately 60 days of life The goal of an ED provider is to suspect BA and facilitate its diagnosis and subsequent definitive surgical care to improve patient outcomes In patients who have undergone surgical correction, an ED provider must recognize high-risk complications, including ascending cholangitis, as well as progression of underlying disease leading to cirrhosis, portal hypertension, and liver failure CLINICAL PEARLS AND PITFALLS Patients with BA have an elevated conjugated (direct) bilirubin shortly after birth, even within the first 24 to 48 hours of life According to the American Academy of Pediatrics, all infants with persistent jaundice beyond to weeks of age should have their conjugated bilirubin measured to evaluate for cholestasis BA should be considered in any young infant with even minimal conjugated hyperbilirubinemia (greater than normal) regardless of the ratio to unconjugated bilirubin Identification within the first 30 to 45 days of life leads to improved outcomes Patients with acholic stools should be investigated for biliary disease, however acholic stools and hyperpigmented urine are relatively late findings Cholangitis is the most common complication after a hepatoportoenterostomy (Kasai) procedure Current Evidence ... after birth, even within the first 24 to 48 hours of life According to the American Academy of Pediatrics, all infants with persistent jaundice beyond to weeks of age should have their conjugated