TROPICAL PANCREATITIS In an 11 Year Old Boy
ASN KISHAN*, MS VENKATRAMAN**,M PAUL KORATH***, K JAGADEESAN****
*Surgical Registrar; **Consultant in Surgery; ***Chief Physician; ****Professor of Surgery, Director, KJ Hospital, 927, PH Road, Chennai 600 084.
Pancreatic diseases in children compromise acute Pancreatitis, congenital anomalies that may involve pancreas, diseases causing chronic pancreatic insufficiency and chronic pancreatitis. Common causes of acute pancreatitis in children are trauma, viral infections (mumps, viral hepatitis), ascariasis, pancreas divisum, choledochal cysts, hyperlipidaemia and hereditary pancreatitis.[1-3] Chronic pancreatic insufficiency without pancreatitis is seen in children suffering from cystic fibrosis, Shwachman syndrome, congenital enzyme deficiencies, enterokinase and lipase, Co-lipase and trypsin.1 Chronic pancreatitis in children can be due to hereditary pancreatitis; idiopathic chronic pancreatitis, tropical chronic pancreatitis, hypertriglyceridaemia, hyperparathyroidism.[1,3-5] All these types of pancreatitis can present with repeated acute attacks and progress to chronic calcific pancreatitis. We present a case of an 11 year old boy who was diagnosed as having tropical chronic pancreatitis.
An 11 year old boy presented with history of para-umbilical pain since 6 years. The pain was of periodical nature present for about 5-6 months in a year, associated with vomiting. The patient during this time would lose weight and become very weak and tired. The pain was intermittent and dull aching type sometimes radiating to the back. The patient did not have any family history of similar complaints. On examination he was a very lean built boy with gross pallor. Per abdominal examination revealed localized rigidity in the epigastrium but no tenderness or distension.
X-ray of the abdomen revealed a radio opaque shadow in the region of pancreas and the left kidney. Ultrasound confirmed the diagnosis of pancreatitis calculi with areas of calcification in the pancreatic head and renal calculi. Endoscopic Reterograde Cholangio Pancreatography (ERCP) was done which showed ductal obstruction and the CT scan done later showed marked dilatation of the pancreatic duct. The blood examinations showed marked elevations of serum Amylase, Alkaline phosphatase, and sugar. His haemoglobin was markedly low, and his stomach aspirate tested positive for occult blood. Hence a diagnosis of tropical pancreatitis was made based on the investigations.
He underwent modified Puestow’s procedure (lateral pancreaticojejunostomy) for his complaint and he showed marked improvement in his symptoms. His weight increased steadily, and his blood sugar came back to normal during his stay in the hospital.
He was all right for the next 2 years and showed good recovery in his day-to-day activity. He was readmitted after 2 years for the complaints of pain and vomiting present for 3 days, and at that time was diagnosed as having a high intestinal obstruction. For the same he was treated conservatively, and he recovered well. He came back with pain abdomen after about a month, when his blood examination revealed a mild increase in serum Amylase, Alkaline phosphatase, and sugar. For the same he was managed conservatively and he went back fully recovered.
He was examined and has been reinvestigated now as a follow up (4 years). He does not give any history of any attacks of acute pain abdomen or any other symptoms related to pancreas. All his investigation has showed values within normal limits and he has gained weight. The ultrasound showed calcific pancreas but no evidence of any inflammation.
Tropical Calcific Pancreatitis
Chronic tropical calculus pancreatitis is a progressive disorder that presents in childhood with recurrent abdominal pain, progressing to diabetes by puberty. Idiopathic recurrent pancreatitis has recently been associated with higher frequency of cystic fibrosis gene mutations. Tropical calcific pancreatitis though initially described from southern, India is seen in all parts of our country.[4,5] This type of pancreatitis is seen exclusively in tropics. It is also charactized by recurrent episodes of abdominal pain, protracted malnutrition, and ketosis resistant diabetes. Ten per cent patients with tropical calcific pancreatitis develop pancreatic cancer. Almost one third of patients with tropical calcific pancreatitis get recurrent episodes of pain in childhood can develop diabetes in childhood. Dense calcification is seen in pancreatic parenchyma. Though exact aetiology of tropical chronic pancreatitis is not known, malnutrition with protein deficiency, cassava (tapioca) toxicity, impaired immune response, viral infection and genetic susceptibility have been considered as various factors in the aetiopathogenesis.[4,5] As is with other forms of chronic pancreatitis treatment of chronic calcific pancreatitis includes control of diabetes, relief of pain with analgesics, pancreatic enzyme replacements, endoscopic or surgical decompression of dilated ducts and removal of pancreatic calculi.
Surgical decompression of the pancreatic duct in patients with chronic pancreatitis relieves pain in 80-90% of subjects, but its effect on exocrine and endocrine pancreatic function is not clear. Therapeutic use of lexipafant opens the field to new powerful therapies designed to reduce the systemic inflammatory response syndrome and thus reduce the morbidity and mortality significantly.
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