Pancreatitis and pancreatic disorders — structured clinical encounter

Candidate instructions

You are the paediatric registrar in the emergency department. An eight-year-old boy with epilepsy has been referred with severe abdominal pain. You have ten minutes to assess the child, establish the diagnosis, outline the early management, address the medication, and plan the follow-up. You will be asked to present your assessment and management plan to the examiner. [2]

The encounter

History

The boy describes two days of severe, constant pain in the upper abdomen that goes through to his back, worse after eating, with nausea and three episodes of vomiting. He has had no fever, no diarrhoea and no recent viral illness. He was diagnosed with epilepsy at age five and has been on valproate for three years with good seizure control. He has had no previous similar episodes. There is no family history of pancreatitis or pancreatic disease. He fell off his bike two weeks ago but did not injure his abdomen. [9]

Examination

He is alert but in pain, tachycardic at one hundred and ten, with a temperature of thirty-seven point eight degrees. His abdomen is soft with marked tenderness in the epigastrium, no guarding or rigidity, and bowel sounds are present but reduced. There is no jaundice and no palpable mass. [2]

Investigations

His serum lipase is six times the upper limit of normal. His full blood count shows a mild leucocytosis. His electrolytes, including calcium, are normal, as are his liver function tests and triglycerides. An abdominal ultrasound shows an enlarged, oedematous pancreas with a small amount of peripancreatic fluid, no gallstones and no biliary dilatation. [1]

Marking domains

Domain 1 — Diagnosis (5 marks)

• Applies the NASPGHAN criteria: at least two of three features — characteristic abdominal pain (present), lipase at or above three times the upper limit of normal (present — six times), and imaging consistent with pancreatitis (present — enlarged oedematous pancreas on ultrasound). [1]
• Identifies the likely trigger as valproate, one of the commonest medication causes of paediatric pancreatitis. [9]

Domain 2 — Early management (6 marks)

• Starts early aggressive hydration with isotonic crystalloid at one and a half to two times maintenance for the first twenty-four to forty-eight hours, titrated to urine output and clinical response. [2]
• Provides adequate analgesia with age-appropriate opioids, because acute pancreatitis is severely painful and adequate analgesia is a priority. [2]
• Plans early enteral feeding within forty-eight to seventy-two hours as the child improves, starting with clear fluids and advancing to a low-fat diet, because early feeding reduces complications and length of stay. [2]
• States that prophylactic antibiotics are not recommended unless there is documented or suspected infected necrosis. [2]

Domain 3 — Drug management (4 marks)

• Stops valproate as the likely trigger and engages the neurology team for an alternative antiseizure medication. [9]
• Explains that valproate-induced pancreatitis can occur at any time during treatment and that the drug should not be rechallenged. [9]

Domain 4 — Follow-up and prevention (5 marks)

• Confirms full biochemical recovery with a normal lipase before discharge. [2]
• Counsels the family on the drug trigger and the importance of avoiding valproate permanently. [9]
• Plans surveillance for recurrence and, if further episodes occur, a genetic panel including PRSS1, SPINK1, CFTR and CTRC, a metabolic screen and a magnetic resonance cholangiopancreatography. [5]

Examiner feedback prompts

• What is the diagnostic threshold for lipase in paediatric acute pancreatitis? (At or above three times the upper limit of normal.) [1]
• Why has the practice shifted from prolonged fasting to early enteral feeding? (Early feeding within forty-eight to seventy-two hours reduces complications, infection and length of stay compared with bowel rest.) [2]
• What would change your management if the child had organ dysfunction or severe local complications? (Escalation to paediatric intensive care, cross-sectional imaging for necrosis, and a multidisciplinary approach.) [2]