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Objectives Pancreas divisum (PD) is a risk factor in children for the development of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (mPES) may be of clinical benefit, however, the clinical outcomes from endotherapy remain unclear. We sought to review the outcomes and safety of therapeutic ERCP in children with PD. Methods We performed a retrospective chart of children with PD who underwent an ERCP between February 2012 and December 2018. Pertinent patient, clinical and procedure information was collected including procedure-related adverse events. A follow-up questionnaire of the parent was conducted to determine the clinical impact from endotherapy. Results Fifty-eight ERCPs were performed in 27 patients (14 boys; mean age: 9.7 years, range 2-19) with PD. All patients underwent a successful mPES. A genetic variant was identified in 19/26 (73%) tested patients. Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58). Median follow-up interval from first ERCP intervention to questionnaire completion was 31.5 months (range: 4--72 months). Of the 20 questionnaire responders, 13 reported clinical improvement from endotherapy. Conclusions The majority of children from our PD cohort possessed at least 1 genetic variant. Most questionnaire responders had a favorable response to endotherapy. PEP rate was comparable with that of prior reports in adult patients.

Background/objectives Drug induced acute pancreatitis (DIAP) as one of the acute pancreatitis (AP) risks factors is a poorly understood entity. The aim of the current study was to compare the characteristics and course of DIAP cases in children presenting with a first attack of AP. Methods Patients presenting with AP were included in a prospective database. We enrolled 165 AP patients that met criteria for inclusion. DIAP patients were included in that group if they were exposed to a drug known to be associated with AP and the rest were included in the non-drug induced-acute pancreatitis (non-DIAP) group. Results DIAP was observed in 40/165 (24%) of cases, 24 cases had drug-induced as the sole risk factor, and 16 had DIAP with another risk factor(s). The two groups were similar in intravenous fluid and feeding managements, but ERCP was more commonly performed in the non- DIAP group, 14 (11%), vs 0% in the DIAP group, p = 0.02. Moderately severe [9 (23%) vs 11 (9%)] and severe AP [7 (18%) vs 6 (5%)] were more commonly associated with DIAP than non- DIAP, p = 0.001. DIAP was more commonly associated with ICU stay, 10 (25%), vs 12 (10%), p = 0.01, hospital stay was longer in DIAP median (IQR) of 6 (3.9–11) days vs 3.3 (2–5.7) days in non- DIAP, p = 0.001. The DIAP group had a significantly higher proportion of comorbidities (p Conclusions DIAP is a leading risk factor for a first attack of AP in children and is associated with increased morbidity and severity of the pancreatitis course. DIAP warrants further investigation in future studies.

Introduction Pediatric chronic pancreatitis is increasingly diagnosed. Endoscopic methods [endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)] are useful tools to diagnose and manage chronic pancreatitis. Pediatric knowledge and use of these modalities is limited and warrants dissemination. Methods Literature review of publications relating to use of ERCP and EUS for diagnosis and/or management of chronic pancreatitis with special attention to studies involving 0--18 years old subjects was conducted with summaries generated. Recommendations were developed and voted upon by authors. Results Both EUS and ERCP can be used even in small children to assist in diagnosis of chronic pancreatitis in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15 kg for EUS and 10 kg for ERCP can be technically challenging. These procedures should be done optimally by appropriately trained endoscopists and adult gastroenterology providers with appropriate experience treating children. EUS and ERCP-related risks both include perforation, bleeding and pancreatitis. EUS is the preferred diagnostic modality over ERCP because of lower complication rates overall. Both modalities can be used for management of chronic pancreatitis -related fluid collections. ERCP has successfully been used to manage pancreatic duct stones. Conclusion EUS and ERCP can be safely used to diagnose chronic pancreatitis in pediatric patients and assist in management of chronic pancreatitis-related complications. Procedure-related risks are similar to those seen in adults, with EUS having a safer risk profile overall. The recent increase in pediatric-trained specialists will improve access of these modalities for children.

OBJECTIVES To utilize a Luminex platform to examine multiple cytokines simultaneously as well as clinical laboratory testing to identify markers that predict acute pancreatitis severity in the pediatric population on admission. STUDY DESIGN Patients (

Objective The natural course of patients who develop acute pancreatitis (AP) can range from mild to severe acute pancreatitis (SAP). The aim of this study was to evaluate for early predictors of developing SAP during the first episode of AP in a prospective pediatric cohort. Methods Clinical data were prospectively collected and subsequently analyzed for pediatric patients presenting with their first episode of AP between March 2013 and January 2017 to Cincinnati Children's Hospital Medical Center. Results A total of 118 patients were included in the analysis, and 22 (18.6%) developed SAP. Patients who developed SAP had significantly higher values of blood urea nitrogen (BUN) (P = 0.007), magnesium (P = 0.04), glucose (P = 0.03), sodium (P = 0.03), and C-reactive protein (P = 0.02). A logistic regression model with BUN as a predictor of SAP was superior to any other combination of variables (area under the receiver operating characteristic curve, 0.75; 95% confidence interval, 0.61-0.89; sensitivity, 63%; specificity, 81%; positive predictive value, 43%; negative predictive value, 91%). Conclusions This study generated a predictive model using elevated BUN as a significant predictor of SAP. The findings are useful for early identification of pediatric patients at higher risk of developing SAP.

To determine the diagnostic sensitivity of serum biomarkers and imaging in the diagnosis of acute pancreatitis in children.This was a cross-sectional analysis of prospective registry data for children (age21 years) whose first documented attack of acute pancreatitis occurred between March 2013 and October 2016 at a single-institution, tertiary care center. Main outcome was sensitivity of serum biomarkers and of imaging modalities, measured via descriptive statistics.In total, 112 children met the criteria for acute pancreatitis; 57 (51%) were male with a median age of 13.4 years (IQR 9.3-15.8 years). Serum amylase and lipase levels were obtained in 85 (76%) and 112 (100%) patients, respectively. Imaging was performed in 98 (88%) patients, with abdominal ultrasound (US) performed in 84 (75%) and computed tomography and/or magnetic resonance imaging performed in 46 (41%) patients. Fifty-three (47%) patients met all 3 diagnostic criteria (clinical, biochemical, and imaging) for acute pancreatitis. Laboratory testing had a 5.4% false-negative rate for acute pancreatitis. Serum lipase alone and amylase alone were 95% (95% CI 89%-98%) and 39% (95% CI 28%-50%) sensitive for acute pancreatitis, respectively. Imaging (any modality) was 61% sensitive (95% CI 51%-71%) for acute pancreatitis with a 34% false-negative rate. US alone was 52% (95% CI 41%-63%) sensitive for acute pancreatitis and computed tomography/magnetic resonance imaging was 78% (95% CI 63%-89%) sensitive. Combinations of diagnostic criteria performed no better than laboratory testing alone.The majority of children coming to medical attention with their first documented occurrence of acute pancreatitis have characteristic symptoms. Serum lipase is highly sensitive for the diagnosis of acute pancreatitis, and serum amylase is moderately sensitive. Imaging, particularly US, is only moderately sensitive, and cross-sectional imaging provides greater sensitivity for diagnosing acute pancreatitis.

The aims of the study were to describe infliximab adherence in a pediatric inflammatory bowel disease cohort, to identify demographic and disease factors associated with adherence, and to examine differences in acute care use among adherent and nonadherent patients. Charts of patients who received infliximab at the Children's Hospital of Wisconsin (CHW) between October 2010 and October 2012 were retrospectively reviewed. A total of 151 patients met the inclusion criteria; 91.4% of the patients were adherent. Nonadherent patients had more emergency room visits and hospitalizations than adherent patients. The study is the first to show high adherence rates to infliximab in a pediatric cohort.

among other lay presentations.It is commonly assumed that this is a small town or ruralissue.Ourhypothesis,however,isthatthisisamuchmorewidely distributed problem that affects all of mid-Americabetween the Allegheny and the Rocky Mountains, and insomepartsofbothcoasts.Arapidlyburgeoningamountofliterature, which is referenced in this article, and describesthis “surgeon shortage,” has been developing in both layand professional texts. This shortage has been difficult toquantifynationallyandlocally;consensusfiguresshowthat7.68 general surgeons per 100,000 population in 1981dropped to 5.69 in 2005. Interestingly, in the same timeperiod, the urban surgeon ratio fell 27%, and the ruralsurgeon ratio fell 21%.

Pain from chronic pancreatitis leads to disability, malnutrition, and narcotic dependence. This study demonstrates the efficacy of bilateral thoracoscopic splanchnicectomy in reducing pain associated with chronic pancreatitis. This study reviews results from this procedure between 1998 and 2006. Data included pain levels, hospital admissions, nutritional status, and the duration between splanchnicectomy and pancreatic resection. Narcotic use was determined from the Kentucky All Schedule Prescription Electronic Reporting system. Fifty-four patients underwent splanchnicectomy with technical success in 98 per cent and immediate symptom relief in 43 per cent. Additional surgery occurred in 44 per cent (average time to surgery was 26 months). Failure of pain relief occurred in 17 per cent, early recurrence (6–12 months) occurred in 15 per cent, and 68 per cent had over a year of relief. Admissions decreased from 5.8 to 2.9 post surgery. Average pain levels decreased from 8.7 to 6.1 post surgery ( P < 0.001). Kentucky All Schedule Prescription Electronic Reporting demonstrated decreased or stable narcotic use in half of the patients. Over half (55%) maintained or gained weight, whereas 39 per cent experienced weight loss. Discharge occurred 24-hours after surgery. Bilateral thoracoscopic splanchnicectomy demonstrates a positive impact on pain control, hospital admissions, nutritional status, and narcotic use. Thoracoscopic splanchnicectomy is an effective and safe option in the treatment of pain from chronic pancreatitis.

Pancreas divisum is the most common anatomic variant of pancreatic development and may lead to pancreatitis. This study evaluated the efficacy of endoscopic stenting in patients with chronic pancreatitis due to pancreas divisum.Between 1993 and 2005, 32 patients with chronic pancreatitis due to pancreas divisum were treated with endoscopic stenting. Each patient underwent an endoscopic retrograde cholangiopancreatography to confirm the diagnosis of pancreas divisum prior to endoscopic stenting. A survey was conducted by telephone conversation to evaluate pain intensity, symptom relief, hospital admissions, quality of life and pain medication usage, which was verified by a statewide narcotic electronic database. Eight of the 32 patients were unavailable for the interview and were not included in the analysis of the study. Results are expressed as mean +/- standard error of the mean (SEM).Twenty-four patients were followed up for a period of 59.6 months. The overall pain level average in the 24 patients decreased significantly from 8.9 +/- 0.4 pre-stenting to 3.9 +/- 0.7 post-stenting (P0.05) on a scale of 1 to 10. The number of hospital admissions per year in these patients decreased significantly from 7.3 +/- 2.1 pre-stenting to 2.1 +/- 0.4 post-stenting (P0.05). Pain medication usage reported by the patients found a decrease in 58% of patients, 21% remained the same, and 13% increased their usage. There was improvement in nausea (67%), vomiting (63%), and chronic pain (75%). Thirteen patients (55%) were treated endoscopically without requiring surgery and 11 (45%) patients required surgery after stenting. These 11 patients had surgery an average of 25 months post-stenting. The complication rate of post-procedural pancreatitis was 3.4%. No mortality was reported in this study.Endoscopic stenting of the pancreatic duct is a safe and effective first treatment for patients with pancreatitis secondary to pancreas divisum. Surgery, when performed for endoscopic stenting failure, is effective as an adjunctive treatment.