Viral Pancreatitis in Paediatrics

Overview

Viral Causes

"Infections, particularly with viruses, are frequently associated with childhood pancreatitis. Enteroviruses, particularly coxsackievirus, are associated with idiopathic AP. Pancreatitis has been reported in children with EBV infections. Pancreatitis in children is often attributed to mumps virus on the basis of abdominal pain and an elevated serum amylase value with parotitis." — Sleisenger & Fordtran's Gastrointestinal and Liver Disease

Broader Paediatric Aetiology Context

• Trauma (especially blunt abdominal trauma — children more susceptible due to less protective abdominal musculature; non-accidental injury must be considered)
• Medications: valproate (most common drug cause; can cause severe necrotising pancreatitis), L-asparaginase, corticosteroids (3rd most common cause at children's hospitals), 6-mercaptopurine, azathioprine, tetracyclines, oral contraceptives
• Infections (viral as above; also Mycoplasma pneumoniae, ascariasis in endemic regions, HIV-associated)
• Biliary tract disease (gallstones less common pre-puberty but must be excluded)
• Systemic diseases: Henoch–Schönlein purpura, Kawasaki disease, SLE, haemolytic uraemic syndrome, diabetic ketoacidosis
• Metabolic: hypertriglyceridaemia, hypercalcaemia, malnutrition
• Structural: choledochal cyst, pancreas divisum, pancreatic duct anomalies
• Genetic: CF, hereditary pancreatitis (PRSS1, SPINK1, CFTR mutations) — gene mutations found in ~48% of recurrent AP and ~73% of chronic pancreatitis cases in children (INSPPIRE cohort)

Clinical Features

• Acute onset epigastric or periumbilical pain (62–89% of cases)
• Nausea and vomiting (40–80% of older children; only 28% of children <2 years)
• Back pain/radiation to the back: <10% (much less common than in adults)
• Infants/toddlers: vomiting, fever, irritability, abdominal distension
• On exam: guarding or distension in <50%; Grey Turner sign in ~2%
• Child often lies on their side with knees flexed

Diagnosis

• Elevated lipase ≥3× ULN (82–100% sensitive in children) — preferred over amylase
• Also check amylase (some cases have normal lipase)
• Important caveat: Normal amylase levels are lower in young children — salivary isoamylase matures before pancreatic isoamylase (pancreatic isoamylase may be absent before 3 months and not at adult levels until ~10 years). In mumps, elevated amylase may be of salivary origin — lipase confirms pancreatic involvement.
• Enzyme level does NOT correlate with disease severity
• Obtain: electrolytes including calcium, LFTs, lipid profile
• Imaging: Ultrasound first (no radiation, sensitive for gallstones/biliary anomalies); CT if trauma suspected or complications (necrosis, haemorrhage, fluid collections) are of concern
• In viral pancreatitis specifically: serology for mumps (IgM), EBV, Coxsackie, etc. to confirm aetiology

Management

1. Aggressive IV fluid resuscitation (normal saline or lactated Ringer's) — intra-abdominal third-spacing and multi-organ failure are potential complications
2. Pain management (analgesia)
3. Pancreatic rest — NG decompression if vomiting
4. Nutritional support — enteral preferred; TPN if enteral not feasible
5. Identify and treat the underlying cause (e.g., stop offending drug, treat underlying infection)
6. No evidence for anticholinergics or somatostatin analogues in children
7. Operative intervention reserved for complications: haemorrhage, infected pancreatic necrosis, pseudocyst

Course and Complications

• The vast majority of paediatric cases are simple oedematous pancreatitis — haemorrhagic and necrotising forms are uncommon but occur in immunosuppressed children
• Recurrent AP occurs in ~10% after a first episode; recurrent cases warrant investigation for structural/anatomic abnormality or genetic aetiology
• Viral pancreatitis is usually self-limiting with supportive care

Key Differences from Adults