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Case Reports Indian Pediatrics 2001; 38: 414-417 |
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Ascariasis Associated Hemorrhageic Pancreatitis |
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Acute pancreatitis is among the rarer causes of acute abdomen in children and represents a diagnostic challenge. It has numerous causes, an obscure pathogenesis, only few effective remedies and sometimes unpredictable outcome(1). After cystic fibrosis acute pancrea-titis is the next common pancreatic disorder in children. Mumps, viral infection, drugs, biliary microlithiasis and blunt abdominal injuries account for other known etiologies. Acute hemorrhagic pancreatitis is the most severe form of acute pancreatitis which is rare in children and often life threatening(2). We report a case of acute hemorrhagic pancreatitis in a girl with roundworm (ascaris) infestation.
A 9-year-old female child was admitted with pain in abdomen for three days with associated vomiting and distention of abdomen for two days. The pain started around umbilicus and was radiating to upper abdomen. Pain was initially colicky but later became continuous. There was no history of fever. She had vomited two roundworms but had not passed flatus or stools since pain. There was no history of jaundice or passage of worms per rectally. At the time of admission in emergency, the child was pale, toxic and febrile with a pulse of 110/min and BP of 96/60 mmHg. The abdomen was distended. There was rigidity and guarding with rebound tenderness all over the abdomen. Fluid thrill and shifting dullness were also positive. Her Hb was 9.2 g/dl; TLC 18300/cu mm, prominently neutrophils; blood sugar 113 mg/dl; S. Calcium 8.7 mg/dl, S. amylase 458 IU. X-ray abdomen revealed distended bowel loops with air fluid levels. In view of deteriorating condition an emergency laparotomy was performed with a provisional diagnosis of acute intestinal obstruction with strangulation of bowel. On exploration, about one litre of brownish black fluid was aspirated from the peritoneal cavity. There was extensive mesentric and omental fat necrosis and pancreas was markedly inflamed with surrounding hematoma. There were ecchy-mosis of posterior stomach wall and of transverse colon. Roundworms were seen in the lumen of jejunum. Peritoneal lavage with normal saline was done. A sump drain was put in the lessor sac, another drain was put in the pelvis and abdomen was closed. Post operative recovery was uneventful. Pelvic drain was removed on 6th day while the sump drain continued to drain 50-100 ml yellowish brown fluid till 10th day. After removal of the sump drain there was 10-20 ml daily discharge which continued for another 8 days and finally stopped gradually. She was dewormed in the post-operative period. Before discharge, USG of abdomen was done which showed, bulky and irregular outline of pancreas with no intra-abdominal fluid collection. No complications were noted in a follow-up of 3 months.
The clinical picture of acute pancreatitis is heterogeneous in children and therefore a high index of suspicion is required(3). A history of abdominal trauma, drug intake and exposure to infectious diseases should be looked for. The family history should be screened for metabolic and hereditary conditions associated with pancreatitis. Abdominal pain is the most frequent symptom. Pain is sudden in onset but may be slow or gradual. Although, the most common location is the epigastrium, other locations do also exist. The typical pain radiation to back observed in adults is invariably missing in 60-90% of children. Other accompanying symptoms are vomiting, nausea and anorexia(4). The spectrum of acute pancreatitis ranges from congenital, structural or inherited disorders to trauma, infections, drugs and biliary tract diseases. Idiopathic pancreatitis is the commonest cause of acute pancreatitis in children (22%). Other causes include trauma (20%), infection (15%), biliary tract disease (14%), drugs (13%), congenital anomalies (5%) and miscellaneous like scorpion sting, post operative and post transplantation (11%)(3-7). The sensitivity of amylase in pediatric acute pancreatitis is less than in adults. Even then, it remains the most widely used single test in acute pancreatitis. Its serum level rises within 2 to 12 hours and in uncomplicated cases it remains elevated for 2 to 5 days. Levels greater than 3 times normal are considered significant for the diagnosis but many investigators report normal amylase in upto 40% of children with pancreatitis(5,7,8). Serum amylase is also valuable in the continuing management of pancreatitis(6). There is considerable controversy about the serum lipase superiority compared to amylase(9). Other diagnostic tools include serum immunoreactive trypsin and ribo-nucleases which were not done in this particular case. Ultrasonography is also a useful investiga-tion in a case of acute pancreatitis. The two major sonographic findings are increased bulk and decreased echogenicity of pancreas(7,10). CT, ERCP and MRI also have a role in diagnosing pancreatitis(10). Management of the acute pancreatitis is largely supportive and the intensity of therapy is dictated by the severity of disease. Peritoneal lavage does decrease the mortality by reducing pancreatic abscess formation without affecting the overall mortality(11). Because of limited surgical experience in childhood acute pancreatitis, most information relies on the adult experience. The indications for surgery however include(12): (i) Exploration in the face of acute abdomen; (ii) Removal of obstruction in the main pancreatic duct or common bile duct; (iii) Drainage of pancreatic fluid collection; and (iv) Debridement of necrotic tissue. Octreotide and somatostatin have been found to be helpful in limiting the severity and management of pancreatic fistula and other complications of acute pancreatitis. In our case, the fistula healed spontaneously(13,14). The prognosis is variable because considerable variations exist in the clinical course of acute pancreatitis in children. In adults the mortality rate in severe hemorrhagic pancreatitis ranges from 15% to 50%. Data regarding mortality in children are scarce. In one report 21% children with acute pancreatitis experienced a fatal outcome(5). In conclusion, a high index of suspicion is required to diagnose pancreatitis. Surgery is advisable in acute pancreatitis when the diagnosis is unclear or when the complications are present(2). Contributors: SDB and UKS managed the case and co–drafted the manuscript. Funding:
None.
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