Pancreatitis

Pancreatitis represents a rare but well-known complication of multiple chemotherapeutic agents, most notably asparaginase, steroids, mercaptopurine and cytarabine. L-asparaginase and PEG-asparaginase derived from E. coli are well described for inducing acute pancreatitis of all degrees of severity with a reported incidence of 2–18 %.

Clinical picture

Classically the pain is epigastric, of sudden onset, gradually intensifying, then becoming constant and radiating through to the back. Clearly, however, it is rare to obtain such a history in children and the index of suspicion should be high in any child post-asparaginase presenting with abdominal pain.

There may be associated nausea or vomiting, fever, tachycardia and, in severe cases, tachypnoea. There is usually upper abdominal tenderness, with or without guarding, abdominal distension and reduced bowel sounds. The Grey Turner and Cullen signs are very rare in children.

Diagnosis

Initial laboratory tests should include: (1) electrolytes, to assess for hypocalcaemia due to precipitation; (2) renal and liver function tests, to check for multiorgan failure as a result of cytokine release from the inflamed or necrotic pancreas; (3) triglycerides, which can cause free radical damage when converted to free fatty acids; and (4) the exocrine enzymes amylase and lipase, elevated levels of which suggest pancreatic autodigestion and are diagnostic hallmarks.

The preferred method for abdominal imaging to determine the extent of pancreatic edema, hemorrhage, necrosis, and other abnormalities is a CT scan with IV contrast.

According to the UKALL 2011 trial, pancreatitis is defined by at least two of the following criteria:

1. Abdominal pain strongly suggestive of acute pancreatitis
2. Serum amylase and/or lipase ≥3 times the upper limit of normal (lipase is preferred over amylase due to greater specificity)
3. Characteristic imaging findings of acute pancreatitis (ultrasonography is often unhelpful but contrast enhanced CT or MRI/MRCP may be useful for both confirming the diagnosis, determining severity, assessing complications, and for guiding potential percutaneous interventions).

Medical treatment

• Ensuring appropriate fluid replenishment and maintaining meticulous fluid balance are crucial.
• Pharmacological Management:
  • Administration of intravenous antibiotics.
  • Utilization of Octreotide can potentially improve the clinical trajectory in cases of hemorrhagic pancreatitis.
• Nasogastric Tubing (NGT) provides no advantage except in instances of unmanageable vomiting or ileus.
• Implementing parenteral nutrition is recommended.

Surgical debridement becomes necessary only when clinical deterioration persists despite adequate antibiotic coverage; percutaneous catheter drainage to irrigate the necrosis can be considered prior to surgical debridement.

References

• Haut C (2005) Oncological emergencies in the pediatric intensive care unit. AACN Clin Issues 16: 232–245
• Kearney SL, Dahlberg SE, Levy DE et al (2009) Clinical course and outcome in children with acute lymphoblastic leukemia and asparaginase-associated pancreatitis. Pediatr Blood Cancer 53:162–167
• Top PC, Tissing JW, Kuiper JW et al (2005) L-asparaginase-induced severe necrotizing pancreatitis successfully treated with percutaneous drainage. Pediatr Blood Cancer 44:95–97