P. V. HAVALDAR ET AL.
Brief Report
Chronic Calcific Pancreatitis in Children by P. V. Havaldar, MD, DCH, V. B. Dhaded, MS, M. S. Kaddi, MD, DCH, and A. S. Godhi, MS Departments of Pediatrics and Surgery, J. N. Medical College, Belgaum, South India
490 SI units. Plain X-ray of the abdomen showed multiple calculi along the pancreas. Abdominal ultrasound was performed which showed a dilated pancreatic duct with multiple calculi in the duct and body of the pancreas. A bilocular pseudocyst was also found. As the pain was severe and the parents would not consent to surgery, Coeliac ganglion block was performed. She was asymptomatic after the ganglion block and was discharged with pancreatic enzyme supplementation.
Case 1 A 6-year-old female child presented with a history of recurrent abdominal colicky pain of 7 months duration. She used to pass white and hard stools. There was no history of fever or symptoms of diabetes mellitus. On examination she was anaemic. Abdominal examination did not show any enlargement of organs or a mass. Investigation revealed normal liver function tests and blood sugar. Serum amylase was 380 SI units. X-ray of the abdomen showed multiple radioopaque calculi of varying sizes along the pancreatic area. She underwent pancreojejunostomy. During the operation the pancreatic duct was found to be dilated and multiple calculi were removed from it. She had an uneventful recovery and was discharged with pancreatic enzyme supplementation. Five years of follow-up did not reveal the development of diabetes mellitus in her.
Case 3 A 6-year-old male child presented with recurrent abdominal pain of 6 months duration. He used to pass pale stools. Systemic examination did not show significant findings. His blood sugar was within normal limits. Serum amylase was 320 SI units. Abdominal ultrasound showed multiple calculi in the distal part of the body and tail of pancreas (Fig. 1). As the calculi were seen only in the distal part of the pancreas he was treated with antispasmodics and pancreatic supplementation without surgical intervention.
Case 2 A 10-year-old female child presented with recurrent colicky abdominal pain of 1 year's duration. She had been treated with antitubercular drugs for presumed tuberculosis. There were no symptoms of diabetes mellitus. On examination she had vitamin A deficiency and mild anaemia. Abdominal examination showed epigastric fullness and tenderness. There was no enlargement of organs or any masses felt. Stools were pale with plenty of fat globules on microscopy. Blood sugar was normal, serum amylase was elevated up to Correspondence: Dr P. V. Havaldar, 4559, Shetti Galli, Belgaum—590002, India. Journal of Tropical Pediatrics
Vol. 38
June 1992
Discussion Chronic pancreatitis is defined as continuing inflammatory disease of the pancreas, characterized by irreversible morphological changes, and typically causing pain and/or permanent loss of function.5 Most of the calcific pancreatites fall in Marked or Grade 5 according to image grading by ERP. 5 So far the largest series of 19 cases of chronic pancreatitis in Indian children has been reported from our neighbouring area of Miraj. 4 Gastroenterologists from different parts of India have seen one or two pediatric cases in their practice.1 Thirteen of the 19 cases reported from Miraj had calcification. Interestingly, calcification was not found in Kerala children unlike their adult counterparts in whom the disease is highly prevalent.6 In all the reports the earliest age of occurrence was 6 years except in one child in whom the diagnosis was made at the age of 3 years. 1-3-4 Two of the three children discussed here were 6 years old and the other was 10 years. Another large series from Uganda describe seven children below the age of 10 years. 3 I Oxford University Press 1992
119
Downloaded from http://tropej.oxfordjournals.org/ at University of Manitoba on June 17, 2015
Chronic calcific pancreatitis as a distinct entity occurring in non-alcoholic adults has been described from all over India and more so from South India. 1 In children, chronic pancreatitis at times associated with calcification has familial predisposition and is called hereditary pancreatitis, this has been well documented in the western world as well as in India. 2 Nonhereditary chronic calcific pancreatitis in children has been reported from African countries and also from India. 3 ' 4 We report on three such children.
P. V. HAVALDAR ET AL.
tM 15 [> PROBE TV LIN -6 SECT-D .. RODE! IB
The aetiology of tropical pancreatitis still remains unclear, but is closely associated with malnutrition and cassava consumption.1 All the three patients were from the poor socio-economic status. Our children had the classical presentation of chronic severe abdominal pain. In some cases there is an associated cyst formation as was the case in one of our patients. Histopathological study done on 35 such adult patients in our pathology department shows the disease occurring diffusely, as well as localized in the pancreas. Glands are markedly shrunken in size with dilated ducts and ductules, and a small number of inflammatory cells with significant fibrosis.1 Though there is association of diabetes mellitus with this form of pancreatitis in adults our observations were not consistent. One of our patients was followed for 5 years without glycosuria. Of the 32 children treated for diabetes mellitus in our institution none had chronic abdominal pain or calcification. It is likely that chronic pancreatitis may progress to loss of pancreatic function and result in diabetes.7 Management of these children varies depending upon the severity of pain and the state of pancreatic function. Pancreojejunostomy is the widely used form of management to deal with the pain and malabsorption. As pain is very severe various forms of nerve blocks and ganglionectomies are also tried with good relief of pain.8 Pancreatic enzyme supplementation after pancreojejunostomy may be required. We had a
satisfactory response in one of our patients followedup for 5 years. A child over the age of 5 years presenting with recurrent severe abdominal pain and symptoms of malabsorption requires investigations with X-rays and ultrasound to exclude pancreatic calculi. More followup studies in confirmed cases are needed to study the natural history of the disease.
2
3. 4. 5. 6. 7. 8
References In: Balakrishan (ed.) Chronic pancreatitis in India. Trivendrum: Indian Society of Pancreatology, 1987. Hadorn HB, Munch G. The exocrine pancreas: development physiology and disease. In Anderson CM, Burke V, Gracey M (eds) Pediatric gastroenterology. London: Blackwell Scientific Publications, 1988; 456-502. Cook GC. The pancreas in the tropics. In: Cook GC (ed.) Tropical gastroenterology. Oxford: Oxford University Press, ELBS Ed. 1980; 193-202. Moah Rao A, Vishalakshi S, Kumar A, Ganapule PR, Fletcher AG. Pancreatitis in children. Ind Pediat 1975; 12: 1177-85. Sarner M, Cotton PB. Classification of pancreatitis. Gut 1984; 25: 756-9. Thomas K, Ninan KM, Philip E. Pancreatitis in childhood. Ind Pediat 1973; 10: 93-6. Verma IC. The challenge of childhood diabetes mellitus in India. Ind J Pediat (Suppl) 1989; 56: S33-8. Mahadevan R, Pancreatic lithiasis. A follow-up study of 17 cases. Br Med J 1961; 1: 626-9.
Journal of Tropical Pediatrics
Vol.38
June 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of Manitoba on June 17, 2015
FIG. 1. Abdominal ultrasound showing multiple calcifications in the distal part of the body of the pancreas and in the tail.
Brief Report
Chronic Calcific Pancreatitis in Children by P. V. Havaldar, MD, DCH, V. B. Dhaded, MS, M. S. Kaddi, MD, DCH, and A. S. Godhi, MS Departments of Pediatrics and Surgery, J. N. Medical College, Belgaum, South India
490 SI units. Plain X-ray of the abdomen showed multiple calculi along the pancreas. Abdominal ultrasound was performed which showed a dilated pancreatic duct with multiple calculi in the duct and body of the pancreas. A bilocular pseudocyst was also found. As the pain was severe and the parents would not consent to surgery, Coeliac ganglion block was performed. She was asymptomatic after the ganglion block and was discharged with pancreatic enzyme supplementation.
Case 1 A 6-year-old female child presented with a history of recurrent abdominal colicky pain of 7 months duration. She used to pass white and hard stools. There was no history of fever or symptoms of diabetes mellitus. On examination she was anaemic. Abdominal examination did not show any enlargement of organs or a mass. Investigation revealed normal liver function tests and blood sugar. Serum amylase was 380 SI units. X-ray of the abdomen showed multiple radioopaque calculi of varying sizes along the pancreatic area. She underwent pancreojejunostomy. During the operation the pancreatic duct was found to be dilated and multiple calculi were removed from it. She had an uneventful recovery and was discharged with pancreatic enzyme supplementation. Five years of follow-up did not reveal the development of diabetes mellitus in her.
Case 3 A 6-year-old male child presented with recurrent abdominal pain of 6 months duration. He used to pass pale stools. Systemic examination did not show significant findings. His blood sugar was within normal limits. Serum amylase was 320 SI units. Abdominal ultrasound showed multiple calculi in the distal part of the body and tail of pancreas (Fig. 1). As the calculi were seen only in the distal part of the pancreas he was treated with antispasmodics and pancreatic supplementation without surgical intervention.
Case 2 A 10-year-old female child presented with recurrent colicky abdominal pain of 1 year's duration. She had been treated with antitubercular drugs for presumed tuberculosis. There were no symptoms of diabetes mellitus. On examination she had vitamin A deficiency and mild anaemia. Abdominal examination showed epigastric fullness and tenderness. There was no enlargement of organs or any masses felt. Stools were pale with plenty of fat globules on microscopy. Blood sugar was normal, serum amylase was elevated up to Correspondence: Dr P. V. Havaldar, 4559, Shetti Galli, Belgaum—590002, India. Journal of Tropical Pediatrics
Vol. 38
June 1992
Discussion Chronic pancreatitis is defined as continuing inflammatory disease of the pancreas, characterized by irreversible morphological changes, and typically causing pain and/or permanent loss of function.5 Most of the calcific pancreatites fall in Marked or Grade 5 according to image grading by ERP. 5 So far the largest series of 19 cases of chronic pancreatitis in Indian children has been reported from our neighbouring area of Miraj. 4 Gastroenterologists from different parts of India have seen one or two pediatric cases in their practice.1 Thirteen of the 19 cases reported from Miraj had calcification. Interestingly, calcification was not found in Kerala children unlike their adult counterparts in whom the disease is highly prevalent.6 In all the reports the earliest age of occurrence was 6 years except in one child in whom the diagnosis was made at the age of 3 years. 1-3-4 Two of the three children discussed here were 6 years old and the other was 10 years. Another large series from Uganda describe seven children below the age of 10 years. 3 I Oxford University Press 1992
119
Downloaded from http://tropej.oxfordjournals.org/ at University of Manitoba on June 17, 2015
Chronic calcific pancreatitis as a distinct entity occurring in non-alcoholic adults has been described from all over India and more so from South India. 1 In children, chronic pancreatitis at times associated with calcification has familial predisposition and is called hereditary pancreatitis, this has been well documented in the western world as well as in India. 2 Nonhereditary chronic calcific pancreatitis in children has been reported from African countries and also from India. 3 ' 4 We report on three such children.
P. V. HAVALDAR ET AL.
tM 15 [> PROBE TV LIN -6 SECT-D .. RODE! IB
The aetiology of tropical pancreatitis still remains unclear, but is closely associated with malnutrition and cassava consumption.1 All the three patients were from the poor socio-economic status. Our children had the classical presentation of chronic severe abdominal pain. In some cases there is an associated cyst formation as was the case in one of our patients. Histopathological study done on 35 such adult patients in our pathology department shows the disease occurring diffusely, as well as localized in the pancreas. Glands are markedly shrunken in size with dilated ducts and ductules, and a small number of inflammatory cells with significant fibrosis.1 Though there is association of diabetes mellitus with this form of pancreatitis in adults our observations were not consistent. One of our patients was followed for 5 years without glycosuria. Of the 32 children treated for diabetes mellitus in our institution none had chronic abdominal pain or calcification. It is likely that chronic pancreatitis may progress to loss of pancreatic function and result in diabetes.7 Management of these children varies depending upon the severity of pain and the state of pancreatic function. Pancreojejunostomy is the widely used form of management to deal with the pain and malabsorption. As pain is very severe various forms of nerve blocks and ganglionectomies are also tried with good relief of pain.8 Pancreatic enzyme supplementation after pancreojejunostomy may be required. We had a
satisfactory response in one of our patients followedup for 5 years. A child over the age of 5 years presenting with recurrent severe abdominal pain and symptoms of malabsorption requires investigations with X-rays and ultrasound to exclude pancreatic calculi. More followup studies in confirmed cases are needed to study the natural history of the disease.
2
3. 4. 5. 6. 7. 8
References In: Balakrishan (ed.) Chronic pancreatitis in India. Trivendrum: Indian Society of Pancreatology, 1987. Hadorn HB, Munch G. The exocrine pancreas: development physiology and disease. In Anderson CM, Burke V, Gracey M (eds) Pediatric gastroenterology. London: Blackwell Scientific Publications, 1988; 456-502. Cook GC. The pancreas in the tropics. In: Cook GC (ed.) Tropical gastroenterology. Oxford: Oxford University Press, ELBS Ed. 1980; 193-202. Moah Rao A, Vishalakshi S, Kumar A, Ganapule PR, Fletcher AG. Pancreatitis in children. Ind Pediat 1975; 12: 1177-85. Sarner M, Cotton PB. Classification of pancreatitis. Gut 1984; 25: 756-9. Thomas K, Ninan KM, Philip E. Pancreatitis in childhood. Ind Pediat 1973; 10: 93-6. Verma IC. The challenge of childhood diabetes mellitus in India. Ind J Pediat (Suppl) 1989; 56: S33-8. Mahadevan R, Pancreatic lithiasis. A follow-up study of 17 cases. Br Med J 1961; 1: 626-9.
Journal of Tropical Pediatrics
Vol.38
June 1992
Downloaded from http://tropej.oxfordjournals.org/ at University of Manitoba on June 17, 2015
FIG. 1. Abdominal ultrasound showing multiple calcifications in the distal part of the body of the pancreas and in the tail.
