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Pancreatitis is defined as inflammation of the pancreas with abdominal pain as the predominant symptom.

The incidence in children (3-13 cases / 100,000 people / year) is significantly lower than that in adults (5-60 cases / 100,000 people / year) and therefore in the international literature we find a small number of studies in children.

Pancreatitis is divided into:

• Acute pancreatitis: self-limiting disease with restoration of the morphology and function of the pancreas
• Acute recurrent pancreatitis: repeated episodes of acute pancreatitis with recovery between episodes
• Chronic pancreatitis: chronic inflammation that leads to progressive pancreatic damage and impairment of pancreatic function.

The majority of cases of acute pancreatitis are idiopathic. The causes of acute pancreatitis in children, however, can be:

• Infections: salmonella, campylobacter, Coxsackie virus, Epstein-Barr virus, E.Coli, mumps virus, etc.
• Systemic – metabolic diseases: cystic fibrosis, hemochromatosis, Crohn’s disease, systemic lupus erythematosus, hyperlipidemia, propionic acidemia, methylmalonic acidemia, etc.
• Drugs: valproic acid, asparaginase, thiopurines, mesalamine, corticosteroids
• Toxic factors: alcohol, passive smoking
• Mechanical – anatomical: injury to the pancreas, anatomical variations of the bile duct or pancreatic duct, pancreatic bifurcation, dysfunction of the pancreatic sphincter (sphincter of Oddi), etc.

In adults, unlike children, the most common causes of acute pancreatitis are cholelithiasis and alcohol use.

The most common cause of chronic pancreatitis in children appears to be genetic, and therefore specific genetic mutations are sought during its investigation.

Acute relapsing pancreatitis (ARPP) is considered a precursor stage of chronic pancreatitis (CP) and a percentage of patients will develop into chronic pancreatitis. Both of these forms of pancreatitis are relatively rare but are now being recognized more and more frequently, especially in the last two decades.

According to international guidelines, two of the following three criteria are required to make a diagnosis of acute pancreatitis. These are abdominal pain of pancreatic origin, involvement of specific biochemical markers (tripling of the normal value of serum amylase and/or lipase) and characteristic imaging findings of pancreatic involvement. However, in children (especially younger ones) the presentation may be insidious and non-specific with symptoms such as a distended abdomen, vomiting, fever and irritability.

Other symptoms may be: diarrhea, lethargy, lower back pain, stool discoloration, nausea, anorexia, hypotension, ascites, dyspnea/pleural effusion.

Regarding the imaging tools available to us, abdominal ultrasound is considered the examination of first choice. Abdominal CT is not considered necessary for the diagnosis of pancreatitis, but is considered an important test for the evaluation of pancreatic necrosis or fluid collection during hospitalization or in the search for lithiasis pancreatitis upon admission.

Endoscopic retrograde cholangiopancreatography (ERCP) is the reference test in the investigation of acute recurrent or chronic pancreatitis and is also used for therapeutic purposes.

Acute pancreatitis is classified as:

• Mild: no organ failure, local or systemic complications, usually resolves within a week
• Moderate: transient organ failure resolving in <48 hours, local complications or exacerbation of comorbidity
• Severe: persistent organ failure for >48 hours, increased risk in the case of systemic inflammatory response syndrome (SIRS)

Intravenous hydration is considered the cornerstone of treatment to correct hypovolemia, improve pancreatic perfusion, and reduce the risk of necrosis and organ damage due to ischemia/hypoxia. An important role in the treatment is played by the patient’s analgesia, where paracetamol and ibuprofen are preferred for mild pain, while opioids have their place in severe pain. Antibiotics are given therapeutically in documented extrapancreatic infection (cholangitis, infections from intravenous catheters, bacteremia, etc.). Their use as a prophylactic in mild or severe forms of the disease is not recommended.

The long-standing dominant treatment of avoiding oral feeding has been abandoned. According to the current guidelines, the Oral feeding should be initiated shortly after the onset of the disease, i.e. within 48 hours of hospital admission in mild pancreatitis and within 72 hours in severe pancreatitis, provided that the patient is hemodynamically stable. A diet with a normal amount of fat can be started within a week after the onset of the disease.

Regarding the prognosis we could say that:

• Most children with acute pancreatitis have a mild form of the disease with a mortality rate of <5%
• About 15-35% of all cases of OP will have relapses, except in cases with early diagnosis of risk factors such as gallstones, drugs, hypertriglyceridemia or hypercalcemia
• About 20-40% of cases with AUP will develop into CP within 2-5 years of the acute pancreatitis disease