Fig. 43.1
Abdominal CT scan showing posttraumatic pancreatic pseudocyst in a child. Note its relation to the pancreas and stomach
Abdominal magnetic resonance imaging (MRI).
Endoscopic retrograde cholangiopancreatography (ERCP) is useful for the diagnosis of various ductal abnormalities or obstructions and may serve as a therapeutic intervention (i.e., sphincterotomy, stone extraction, stent placement).
Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive alternative to ERCP but lacks therapeutic capabilities.
Medical Management
Adequate rehydration.
Analgesia.
Pancreatic rest.
Antacids or H2-histamine blockers are useful to prevent gastritis and reduce duodenal acid exposure.
In severe pancreatitis, oral intake is restricted and parental nutrition is started within 3 days to prevent catabolism.
In cases of intractable vomiting or ileus, nasogastric suction is beneficial to prevent vomiting, manage ileus, and provide pancreatic rest.
Antibiotic therapy is indicated for systemic infections or sepsis.
Surgical Management
Surgical intervention is indicated for:
The management of congenital anatomic defects (e.g., pancreatic divisum).
The management of complications associated with acute pancreatitis :
◦ Pancreatic ascites
◦Intra-abdominal abscess
◦Pancreatic pseudocyst
Acute pancreatic pseudocysts are managed with observation for 4–6 weeks because most resolve spontaneously.
Chronic pancreatic pseudocysts (> 3 mo) are best treated by surgical interventions such as:
◦ Ultrasonography-guided or CT-guided percutaneous drainage
◦ Endoscopic drainage
◦ Internal drainage via cyst gastrostomy or enterostomy
Surgery for pancreatic ductal disruption or compromise (i.e., acute traumatic pancreatitis with ductal injury) is indicated after medical failure.
ERCP or intraoperative pancreatic ductography is valuable in determining the site of ductal disruption and directs surgical decision making to the most appropriate operative procedure.
Operative management of chronic pancreatitis in children is controversial.
Indications for operative intervention include:
◦ Unsuccessful conservative medical therapy
◦ Intractable pain
◦ Impaired nutrition
Surgical options include:
◦ Distal pancreatectomy with Roux-en-Y pancreaticojejunostomy (Duval procedure)
◦ Lateral pancreaticojejunostomy (Puestow procedure)
◦ ERCP sphincteroplasty
◦ Total pancreatectomy and islet cell transplantation
Pancreatic Pseudocyst
Pancreatic pseudocysts are often caused by:
Acute or chronic pancreatitis
Abdominal trauma
Alcohol-induced pancreatitis
Pseudocysts are more often present in chronic pancreatitis patients than in acute pancreatitis patients.
Clinical Features
Pancreatic pseudocyst is commonly asymptomatic.
Children with pancreatic pseudocysts may present with:
