Case 3 :- 3 year old with Gall stone induced Acute Severe Necrotising Pancreatitis with peritonitis and Hypovolemic shock

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Case Summary :- 3 years old girl child presented to us with complaint of pain abdomen predominantly epigastric in location, intermittent in nature, partially relieved with medicines, since 5-6 days. Her abdominal pain had worsened in last 24 hrs and she also had 2 episodes of bilious vomiting. Intensity of pain and general condition of child did not improve hence was referred here. At admission in ER, she was critically sick, with tachycardia, tachypnea, cold & mottled peripheries with impalpable peripheral pulses and low volume central pulses. Child had all the signs ofperitonitis at admission. She was immediately started on fluid resuscitation according to goal directed therapy. Child showed signs of third space losses / vascular leakage and SIRS till day 5 of illness. Fluid and vasoactive agents were continuously titrated according to invasive intra arterial BP, CVP, Lactate, urine output, I/O, PCV. Apart from routine lab tests S. Amylase, S. Lipase and LDH were also sent which all came grossly raised. USG abdomen showed bulky pancreas, hence CECT abdomen was done which confirmed the USG findings

It showed 30-50 % necrosis of pancreas involving body and tail with large peripancreatic collection. There was a gall bladder stone besides massive fluid collections in pleura and peritoneum. Child was put on conservative management and was kept NPO for 5 days to give rest to pancreas and her hemodyanamics were intensively monitored during these days. Gradually hemodynamic parameters got stabilized by day 5. Nasoduodenal feeds were started on day 6. Semisolid diet was introduced on day 8. Antibiotics with good penetration in pancreatic tissue were also given prophylactically.

Learning Points :Acute Pancreatitis used to be one of the rarer cause of abdominal pain in children and was among the least reported of childhood diseases. But now it is being increasingly reported in children also. Pediatricians should also suspect this entity in cases of severe abdominal pain,not responding to usual drugs.