The brief report of Das, et al.(1) gives an impression of non-existence of published work on pancreatic disorders from India. The authors have missed inclusion of two recently published series of childhood pancreatic disorders from India(2,3). One study is that of ERCP in 16 cases of pancreatic disorders in children (Poddar, et al.) and the other on management of 15 cases (Yachha, et al.). It is not clear from the study as to how cases of acute pancreatitis were diagnosed. Authors have mentioned that pancreatic disorders were suspected whenever there was abdominal pain associated with raised serum lipase or amylase or/and suggestive imaging studies. Conditions like appendicitis, intestinal obstruction, intestinal ischemia or perforation, cholecystitis, etc., other than pancreatitis can give rise to 2 to 3 folds elevation of serum amylase. By definition acute pancreatitis is diagnosed when there is upper abdominal pain associated with at-least three times elevation of pancreatic enzymes(4). What were the cut-off levels taken by authors? What criteria were used to diagnose acute pancreatitis in-patients having normal serum amylase (7/28 cases) as shown in Table II? Even imaging studies like USG and CT scan were normal in 4 of 24 cases and 6 of 22 cases respectively, where they were used.

Among the etiology of acute pancreatitis (Table I) authors have mentioned two cases of tuberculosis. Is tuberculosis known to produce acute pancreatitis (literature support)? Interestingly authors have mentioned alpha-1-antitrypsin deficiency as a cause of acute pancreatitis in their series (Table I). Till date the only study available (English literature) on pancreatic diseases and alpha-1-antitrypsin deficiency is by Braxel, et al.(5). This study looked for possible relation between alpha-1-antitrypsin deficiency and pancreatitis in 90 patients with proven pancreatitis (both acute and chronic) and compared them with 549 healthy persons by doing Pi-phenotyping. No significant difference between cases and controls were found and thus the study concluded "alpha-1-antitrypsic deficiency does not play an important role in pancreatic diseases"(5). Mere presence of low serum level of alpha-I-antitrypsin and absence of alpha globulin band on electrophoresis does not prove this association(1).

What were the indications for doing laparotomy in 9 cases? Were these diagnostic or therapeutic? Authors have mentioned tuberculosis, cholelithiasis, trauma, and drugs like valproate as causes of chronic pancreatitis. Trauma and cholelithiasis are known causes of acute pancreatitis but not of chronic pancreatitis(4). Obstruction of main pancreatic duct (usually single stricture) by scars, tumors, cysts or stenosis of the papilla of Vater can produce chronic pancreatitis. Rarely, severe blunt or penetrating trauma to the pancreas can result in stricture of main pancreatic duct that in turn can give rise to chronic pancreatitis. Such like patients following trauma initially develop a phase of severe acute pancreatitis. Was there any such history in two cases of post-traumatic chronic pancreatitis or the history of trauma was just a mere co-incidence? It is true for cholelithiasis also. Occasionally main pancreatic duct stricture can develop following a bout of gall stone-related acute necrotizing pancreatitis. Was there any such history or gallstone was merely a co-incidental findings? Valproate is a known cause of acute pancreatitis irrespective of its duration of exposure(4) but in this study it has been clubbed in the chronic pancreatitis group. Was there any specific reason? One of the cases with chronic calcific pancreatitis had pancreatic ascites. How was this case managed? Endoscopic pancreatic duct stenting is very useful in such setting(2).

Ujjal Poddar,
S.K. Yachha,
Department of Gastroenterology
(Pediatric Gastroenterology),
Sanjay Gandhi Postgraduate Institute of
Medical Sciences,
Raebareli Road,
Lucknow 226 014, India.

1. Das S, Arora NK, Gupta OK, Gupta AK, Mathur P, Ahuja A. Pancreatic diseases in children in a north Indian referral hospital. Indian Pediat~2004; 41; 704-711.

2. Poddar U, Thapa BR, Bhasin DK, Prasad A, Nagi B, Singh K. Endoscopic retrograde cholangiopancreatography in the manage-ment of pancreaticobiliary disorders in children. J Gastroenterol Hepatol 2001; 16: 927-931.

3. Yachha SK, Chetri K, Sara swat VA, Baijal SS, Sikora SS, Lal R, et al. Management of childhood pancreatic disorders: a multi-disciplinary approach. J Pediatr Gastroenterol Nutr 2003; 36: 206-212.

4. DiMagno EP, Chari S. Acute pancreatitis. In: ,Sleisenger & Fordtran’s Gastrointestinal and liver disease, 7th edition. Saunders; Philadelphia; 2002. p 913-941.

5. Braxel C, Versieck J, Lemey G, Vanballenberghe L, Barbaier F. Alpha-I-antitrypsin in pancreatitis. Digestion 1982; 23: 93-96.