Pancreatic Abscess: An Unusual Complication of Pancreatit is in Infancy

Shmuel Katz, Avi Rivkind, Oded Cohen, and Medad Schiller

Jerusalem, Israel

�9 This is the report of the successful surgical t r e a t m e n t of a pancreat ic abscess in a 15-month-o ld girl,

INDEX W O R D S : Pancreat ic abscess.

p ANCREATITIS in infancy and early child- hood is quite unusual. Conservative and

surgical treatment of its main complications-- pseudocysts, ascites, and sepsis--has previously been described in the literature. ~

CASE REPORT

A 15-month-old, previously healthy girl was referred to Hadassah University Hospital from a community hospital because of abdominal distension and generalized peritonitis. Two days prior to her admission there, she developed severe abdominal pain followed by generalized convulsions, coma, recurrent vomiting, and watery diarrhea. On examination she looked extremely sick but her body temperature and physical and neurologic examinations were within normal limits.

Initial laboratory tests in the community hospital revealed normal urinalysis and normal blood chemistry. The WBC was 38,000/mm 3 with a marked shift to the left. Stool cultures were normal. Lumbar puncture was negative. Chest and plain abdominal x-ray showed no pathology. Her general condition deteriorated, and the abdomen became gradually distended and tender. At that stage the patient was referred to our ward for further investigation and treatment.

On admission the patient was fully conscious but looked septic. Her body temperature was 37~ and her pulse rate 160/rain. The abdomen was markedly distended, with ten- derness and muscle guarding mostly in the upper abdomen. Bowel sounds were diminished. Rectal examination revealed watery stool. Blood, urine, and stool cultures were taken and later reported to be sterile. Resuscitation was immediately initiated and included nasogastric suction, intravenous (IV) fluids, electrolytes, and Plasmanate.

The serum amylase was 1,500 IU/100 mL which climbed the next day up to 5,000 IU/100 mL (normal 60 to 200 IU/100 ml). The diagnosis of an acute panereatitis was made. In view of the rising temperature and the septic condition, IV administration of gentamycin, ampicillin, and Trasylol was started.

From the Department o f Pediatric Surgery, Hadassah University Medical Center, Jerusalem, Israel.

Please address reprint requests to Prof. M. Schiller, Chief o f Department o f Pediatric Surgery, Hadassah University Medical Center, Ein Karem, P.O.B. 12000, Jerusalem, Israel.

�9 1983 by Grune & Stratton, Inc. 0022-3468/83/1803~)023501.00/0

The high body temperature (up to 40~ lasted for three days, then returned to normal with an improvement of the general condition and abdominal findings and a return of serum amylase to near normal levels. Repeated chest x-rays were normal. Barium examination of the upper gastrointesti- nal tract was normal. Intravenous fluids and antibiotics were discontinued on the seventh day. Four days later, the temper- ature rose again to 40~ the abdomen became distended, and the serum amylase was 1,200 units/100 mL. Gastric suction was started and IV fluids, antibiotics, and Trasylol were readministered.

Ultrasound study of the upper abdomen demonstrated a cystic formation in the left upper abdomen. Upper gastroin- testinal study with barium showed anterior displacement of the stomach. On the next day, a remarkable mass in the left upper abdomen could be palpated. Needle aspiration revealed cloudy yellowish pancreatic fluid (amylase content of 22,000 IU/100 mL). Gram-negative cocci were found in a direct smear. An encapsulated cavity containing 100 mL of pus was drained through a left-upper transverse incision. Sump catheter No. 24 was inserted to the abscess cavity. Escherichia coli sensitive to ampicillin, cephalosporin, kana- mycin, gentamycin, chloraphenicol, and sulpha compounds was cultured.

The postoperative course was uneventful and the child recovered completely. Two weeks later, a transient elevation of serum amylase with no other gastrointestinal symptoms was detected. Repeated ultrasound study disclosed a small cavity of 3 cm in diameter in the left upper abdomen. The drain was removed a week later, and the child was discharged in a good nutritional condition six weeks after admission.

The etiologic factor causing an acute pancreatitis in the above patient was not identified although multiple diagnostic tests were performed. No family history of abdominal pain suggestive of hereditary pancreatitis was available. Multisys- terns viral cultures and blood titers were normal. Serum triglycerides, cholesterol and free fatty acids, bilirubin, calci- um, phosphorus, alkaline phosphatase, and various transami- nases were normal. A sweat test was normal. Microscopic stool examination for parasites was negative. Upper gastroin- testinal sutdies did not show duodenal malformation, duplica- tion, or displacement. A cholecystogram and cholangiogram excluded pathology in the biliary system. One possible etiolo- gic factor that was suspected, but could not be proved, was that the pancreatic trauma might have been caused by beatings. The skull and skeletal surveys were negative, how- ever. In a follow-up of one year, the patient is completely healthy.

DISCUSSION

Pancreatic abscess is one of the most serious complications of acute pancreatitis. Its occur- rence in 2% to 5% of adults operated for pancrea- titis and its 100% mortality rate in unoperated

306 Journal of Pediatric Surgery, Vol. 18, No. 3 (June), 1983

PANCREATIC ABCESS 307

patients have been emphasized by various authors.5 9 Since it has been shown that adequate surgical drainage of the abscess markedly decreases the morbidity and mortality rates, early diagnosis and treatment can prevent such a dismal outcome. Many reports point out the difficulty in differentiating between pancreatic abscess and pseudocyst, since their clinical and roentgenographic appearance are quite similar; nausea, vomiting, and evidence of a retrogastric or epigastric mass are common to the pseudocyst and pancreatic abscess. Fever, leukocytosis, and other signs of sepsis are the most reliable criteria for differentiating pancreatic abscess from pseu- docyst.10

Cooney and Grosfeld presented their experi- ence of 15 infants and children with pancreatic pseudocyst. 2 A review of 60 additional cases supported their conclusion that internal drain- age, cystogastrostomy, or cystojejunostomy is preferred and avoids complications seen follow- ing external drainage and resection of the pan- creas. Surprisingly, there is no support concern- ing pancreatic abscess in infancy. Is it rare or misdiagnosed?

In adults, the fatal outcome of this complica-

tion can be avoided by early and adequate exter- nal drainage. 5 A delay or failure to achieve effective drainage is always disastrous. On the contrary, conservative treatment and delay of drainage are generally considered optimal in the treatment of pseudocyst. In view of the similar presentation of pseudocyst and pancreatic abscess on one hand, and the extremely different strategy in electing the optimal timing of the correct surgical procedure on the other, prompt diagnosis of a pancreatic abscess is an essential determinant of the overall outcome for the patient with pancreatitis suffering from this complication.

The perioperative treatment of the patient includes nasogastric suction, intravenous sup- port, and administration of antibiotics such as ampicillin and gentamycin to cover most of the enteric organisms cultured in pancreatic ab- scess.

Awareness and early diagnosis of this very unusual complication of acute pancreatitis in childhood, with adequate wide drainage of the abscess and the adjacent necrotic pancreatic material, are essential in preventing a fatal out- come.

REFERENCES

1. Moosa AR: Acute pancreatitis in childhood. Prog Pedi- atrSurg4:lll 127, 1972

2. Cooney DR, Grosfeld JL: Operative management of pancreatic pseudocyst in infants and children. A review of 75 cases. Ann Surg 182:590~596, 1975

3. Buntain WL, Wood JB, Woolley MM: Pancreatitis in childhood. J Pediatr Surg 13:143 148, 1978

4. Rubin SZ, Ein SH: The unusual presentation of pan- creatitis in infancy. J Pediatr Surg 14:146-148, 1979

5. Altemeier WA, Alexander JW: Pancreatic abscess: A study of 32 cases. Arch Surg 87:80-89, 1963

6. Bollooki H, Jaffe B, Gleidman ML: Pancreatic abscess

and lesser omental sac collections. Surg Gynecol Obset 126:1301-1308, 1968

7. Miller TA, Lindenaaer SM, Frey CF et al: Pancreatic abscess. Arch Surg 108:545-551, 1974

8. Jones CF, Polk HC, Fulton RL: Pancreatic abscess. Am J Surg 129:44-47, 1975

9. Camer S J, Tan EGC, Warren KW, et al: Pancreatic abscess: A critical analysis of 113 cases. Am J Surg 129:426- 431, 1975

10. Owens BJ III, Hamit HF: Pancreatic abscess and pseudocyst. Arch Surg 112:42~,5, 1977