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Management of fibrosing pancreatitis in children presenting with obstructive jaundice
F A Sylvester1, B Shuckett, E Cutz
1Division of Gastroenterology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Non-surgical temporary drainage for pediatric fibrosing pancreatitis can relieve bile duct obstruction. However, pancreatic function often deteriorates, leading to insufficiency, necessitating close monitoring before surgical intervention.
Area of Science:
- Pediatric Gastroenterology
- Hepatology
- Surgical Gastroenterology
Background:
- Fibrosing pancreatitis in children typically requires surgery for common bile duct (CBD) obstruction.
- Pancreatic function post-obstruction resolution has not been extensively studied in pediatric cases.
Observation:
- Four children (1.5-13 years) with fibrosing pancreatitis presented with CBD obstruction due to pancreatic head enlargement.
- Biopsies revealed acinar atrophy and fibrosis; parvovirus B19 was identified in one case.
- Temporary CBD drainage was performed in three patients, with one undergoing choledochojejunostomy.
Findings:
- CBD obstruction and pancreatic enlargement resolved after drainage procedures.
- Exocrine pancreatic function significantly deteriorated in three patients, leading to insufficiency within 2-4 months.
- One patient maintained pancreatic sufficiency despite diminished function; no cases of diabetes mellitus were observed.
Implications:
- Non-surgical temporary drainage is a viable initial approach for pediatric fibrosing pancreatitis with CBD obstruction.
- Close monitoring of exocrine pancreatic function is crucial post-drainage due to the high risk of insufficiency.
- This approach may help defer or avoid surgery, but requires careful follow-up to manage potential pancreatic insufficiency.
Background:
Children with fibrosing pancreatitis are conventionally treated surgically to relieve common bile duct (CBD) obstruction caused by pancreatic compression. Residual pancreatic function has not been formally tested in these patients.
Aims:
To evaluate the usefulness of non-surgical temporary drainage in children with fibrosing pancreatitis and to assess pancreatic function after resolution of their CBD obstruction.
Patients:
Four children (1.5-13 years; three girls).
Methods And Results:
Abdominal sonography and computed tomography revealed diffuse enlargement of the pancreas, predominantly the head. The CBD was dilated due to compression by the head of the pancreas. Pancreatic biopsy specimens obtained in three patients showed notable acinar cell atrophy and extensive fibrosis. Cystic fibrosis was excluded. No other cause of pancreatitis was identified. Pancreatic tissue from one patient contained viral DNA sequences for parvovirus B19 detected by polymerase chain reaction; serum IgM to parvovirus was positive. Three patients had temporary drainage of the CBD and one patient underwent a choledochojejunostomy. Serial imaging studies revealed resolution of the CBD obstruction with reduction in pancreatic size. Exocrine pancreatic function deteriorated. Three patients developed pancreatic insufficiency within two to four months of presentation. The fourth patient has notably diminished pancreatic function, but remains pancreatic sufficient. None has diabetes mellitus.
Conclusions:
Temporary drainage of the CBD obstruction is recommended in fibrosing pancreatitis in children along with close monitoring of the clinical course, before considering surgery.
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