Pe d i a t r i c I m a g i n g R ev i ew

Restrepo et al.
Acute Pancreatitis in Pediatric Patients

Pediatric Imaging
Review
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Acute Pancreatitis in Pediatric

Patients: Demographics, Etiology,
and Diagnostic Imaging
Ricardo Restrepo1 OBJECTIVE. The objective of this article is to provide updates on acute pancreatitis in
Heidi E. Hagerott 2 children regarding the imaging findings, causes, and complications based on a review of the
Sakil Kulkarni2 current studies in the pediatrics literature. We discuss the epidemiology of acute pancreatitis,
Mona Yasrebi 3 the role of imaging and imaging findings in the diagnosis of acute pancreatitis, and the causes
and complications of acute pancreatitis.
Edward Y. Lee 4
CONCLUSION. The incidence of acute pancreatitis is increasing in children. Imaging
Restrepo R, Hagerott HE, Kulkarni S, Yasrebi M, plays an important role in the diagnosis of acute pancreatitis because imaging findings can be
Lee EY used to establish the cause of acute pancreatitis, evaluate for complications of acute pancre-
atitis, and possibly predict the course of the disease.

cute pancreatitis is the most com- review the role of various currently available

A mon pathologic entity affecting

Keywords: CT, MRI, pancreatitis, pediatrics, ultrasound
DOI:10.2214/AJR.14.14223
Received December 2, 2014; accepted after revision
May22, 2015.
1
Department of Radiology, Miami Childrens Hospital,
3100 SW 62 Ave, Miami, FL 33155-3009. Address
correspondence to R. Restrepo (ricardo.restrepo@mch.com).
2
Department of Medical Education, Miami Childrens
Hospital, Miami, FL.
3
Department of Medical Imaging, Nemours/A. I. Dupont
Hospital for Children, Medical Imaging, Wilmington, DE.
4
Department of Radiology, Boston Childrens Hospital
and Harvard Medical School, Boston, MA.
This article is available for credit.
AJR 2016; 206:632644
0361803X/16/2063632
American Roentgen Ray Society
the pancreas in children. Accord-
ing to the INSPPIRE (Interna-
tional Study Group of Pediatric Pancreatitis:
In Search for a Cure) Group, acute pancreatitis
is defined as reversible inflammation of the
pancreatic parenchyma when two of the three
following criteria are present: abdominal pain
compatible with acute pancreatitis, serum am-
ylase or lipase value3 times the upper limit in all pediatric age groups over the past 2 de-
of normal, and imaging findings consistent
with acute pancreatitis [1, 2].
Imaging of the pancreas plays an impor-
tant role not only in the diagnosis of acute
pancreatitis but also in the determination of
the underlying cause of acute pancreatitis
and in the detection of complications asso-
ciated with acute pancreatitis [3]. Although
the symptoms that are typical of pancreatitis,
such as abdominal pain and vomiting along
with elevated lipase levels, establish the di-
agnosis in most cases, up to 5% of cases of
acute pancreatitis may be missed in children
if imaging is not performed [4]. The role of
imaging in the early prediction of complica-
tions based on the CT severity index (CTSI)
score and the role of interventional radiolo-
gy in treating complications associated with
acute pancreatitis (i.e., percutaneous catheter
drainage) are being increasingly recognized
in children [2, 5]. In this article, we discuss
the epidemiology, pathophysiology, classifi-
cation, and causes of pancreatitis. We also
imaging modalities (i.e., ultrasound, CT, and
MRI) in the diagnosis of acute pancreatitis
and in establishing the cause.
Demographics and Epidemiology
Acute pancreatitis occurs in all age
groups, even in infants. Recent single-center
and multiinstitutional studies have reported
an increasing incidence of acute pancreatitis
cades [610]. This increase in the reported
incidence of acute pancreatitis in the pediat-
ric population is likely multifactorial. Some
investigators have linked it to an increase in
emergency department visits and testing of
serum amylase and lipase levels in pediatric
patients [8], whereas others have linked it to
increases in referrals to tertiary care centers
[11]. The increase in the incidence of acute
pancreatitis in pediatric patients has also
been linked to the rising incidence of obesity,
a significant independent risk factor for acute
biliary pancreatitis, which is one of the most
common causes of acute pancreatitis in chil-
dren [1214]. Currently, the best estimates
suggest that there are 3.613.2 cases of acute
pancreatitis per 100,000 pediatric individu-
als per year, an incidence that approaches the
incidence of pancreatitis in adults [8, 9]. In a
meta-analysis that spanned almost 4 decades
and generated data that included 589 chil-
dren with acute pancreatitis, the mean age of
patients with the disease was 9.2 2.4 (SD)

632 AJR:206, March 2016


years (range, 1 week21 years) and the male-
to-female ratio was 1:2 [15]. In a more re-
cent study that included 55,012 children with
acute pancreatitis, the disease was found to
be more likely to occur in children older than
5 years old (median age, 17 years) and to oc-
cur slightly more frequently in girls than in
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boys [10].
Pancreatitis causes substantial morbidi-
ty in the pediatric population. It is estimat-
ed that 213 new cases occur annually per
100,000 children [8]. Nearly one-quarter of
children with acute pancreatitis develop a se-
vere complication, and the mortality rate is
approximately 410% despite significant ad-
vances in the treatment of this disease [10,
15]. According to a recent study, the median
inpatient length of stay for children with pan-
creatitis in 2009 was 4 days, and the median
cost of care was approximately $22,663 (in-
terquartile range, $11,923$45,728) [10].
Spectrum of Imaging Findings in
Acute Pancreatitis
The imaging features compatible with
acute pancreatitis in pediatric patients, which
are similar to those seen in adults, include
edema, hemorrhage, or necrosis of the pan-
creatic parenchyma; peripancreatic fat; as-
cites; and pancreatic and peripancreatic col-
lections, the latter of which indicate a recent
episode of acute pancreatitis [2]. Currently,
ultrasound, CT, and MRI are the three most
used imaging modalities for evaluating pan-
creatitis in the pediatric population.
Transabdominal Ultrasound
Transabdominal ultrasound is current-
ly the best initial imaging study of choice to
screen for suspected pancreatitis and to eval-
uate for biliary tree abnormalities in pediat-
ric patients. The glandular and pancreatic duct
size and echogenicity change according to the
childs age and body habitus. These changes
are potentially confounding features when us-
ing ultrasound to evaluate pediatric patients
with suspected acute pancreatitis. The pediat-
ric pancreas is relatively larger than the adult
pancreas, and the pancreatic head in pediatric
patients tends to be more prominent than the
body and tail; these differences in imaging ap-
pearances are potential interpretation pitfalls
for the unwary [16, 17]. The normal pancreat-
ic duct in children is not necessarily visible on
ultrasound: In one study, investigators report-
ed visualization of at least part of the pancre-
atic duct as an echogenic line in up to 85% of
healthy children [18] (Fig. 1). Normal pancre-
AJR:206, March 2016 633
Acute Pancreatitis in Pediatric Patients
Fig. 1Transverse ultrasound image of 2-year-old
girl shows normal pancreas (P). Normal pancreas
is isoechoic to liver (L) and has speckled pattern.
Normal pancreatic duct is partially visualized as
echogenic line (arrow).
atic parenchyma in premature and full-term
infants is hyperechoic to the liver; this appear-
ance is related to the prominent septa with-
in lobules and large amounts of glandular tis-
sue [19] (Fig. 2). After the neonatal period, the
echogenicity of the pancreas is variable; the
pancreas is isoechoic or slightly hyperechoic
relative to the liver. A speckled appearance of
the gland is commonly seen [17, 20] (Fig. 1).
In older children, marked hyperechogenicity
is usually indicative of fatty infiltration, which
can be seen in patients with cystic fibrosis, pa-
tients who are taking steroids, and patients
who are obese. The pancreas is not seen on ul-
trasound in approximately 614% of children
[21]; the percentage increases when pancreati-
tis is present because of increased bowel gas
secondary to aerophagia and ileus [21].
In acute pancreatitis, especially early
in the disease process or in mild cases, the
size and echogenicity of the pancreas on ul-
trasound are unreliable diagnostic features,
in part because of the normal variability of
these features. Diffuse or focal enlargement
of the pancreas is attributable to edema; how-
ever, pancreatic enlargement has been re-
ported to be absent on ultrasound in approxi-
mately 50% of the patients [20]. Decreased
glandular echogenicity is frequently seen, but
the echogenicity may be normal or may even
be increased in children with acute pancreati-
tis [22] (Fig. 3). On ultrasound, a more reli-
able diagnostic feature of acute pancreatitis
is dilatation of the pancreatic duct (16 years
old,>1.5 mm; 712 years old,>1.9 mm; 13 al is mandatory to identify the parenchymal
18 years,>2.2 mm) [18] (Fig. 4). The eval-
uation of the pancreatic duct should be per-
formed, if possible, using high-frequency
ultrasound probes that provide high-resolu-
Fig. 2Increased echogenicity of normal pancreas
(P) on ultrasound image of 1-week-old boy. Note
higher echogenicity of pancreas relative to that of
liver (L) in neonates.
tion images (i.e., 15 MHz) [18, 21, 22]. Poor-
ly defined glandular borders and peripancre-
atic fluid or localized fluid collections can be
seen in the acute setting and are easy to iden-
tify on ultrasound (Fig. 5). Ultrasound is also
useful in the characterization of the margins
(i.e., well defined vs poorly defined) and con-
tents (low-level echoes, septations, debris) of
collections complicating pancreatitis (Fig. 5),
which determine the amenability of the col-
lections to drainage.
CT
The common CT findings of acute pan-
creatitis include varying degrees of focal or
diffuse pancreatic enlargement, focal or dif-
fuse parenchymal hypodensities, parenchy-
mal heterogeneity, indistinctness of the glan-
dular contours, and inflammatory changes in
the peripancreatic fat seen as fat stranding
and thickening of the retroperitoneal fascial
planes (Fig. 6). In mild cases of acute pancre-
atitis or early in the disease process, a nor-
mal pancreas can be seen in up to one-third
of patients on the initial CT examination
[21]. When CT is used to evaluate pancreati-
tis or its complications, IV contrast materi-
changes unless there is a contraindication
to contrast material. Contrast enhancement
of the gland can be variable from homo-
geneous in mild cases, to heterogeneous in
 Restrepo et al.

TABLE 1: MRI and MRCP Protocols in Patients 1218 Years With Acute Pancreatitis or a History of Acute Pancreatitis
Slice Flip
Thickness TR Angle FOVa
Sequences Plane (mm) Slice Gap (mm) (ms) TE (ms) () (cm) Matrix
3 Tb
T2 3D VISTA Coronal 1.5 Overcontiguous 948 200 90 350 325 285
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T2 single-shot Axial 4 0.6 736 80 90 340 340 240

T2 single-shot with FS Axial 4 0.6 799 70 90 340 340 240
In-phase and out-of-phase dual FFE acquisitionsc Axial 5 0.5 180 In phase, 2.3; out of phase, 1.15 55 340 164 146
T2 Radial 40 3042 990 90 200 212 171
eThrive Axial 1.7 0.85 (overcontiguous) 2.6 1.23 10 340 200 140
1.5 Td
T2 3D VISTA Coronal 1.2 Overcontiguous 2000 200 90 350 276 199
T2 single-shot Axial 4 0.4 437 80 90 340 264 212
T2 single-shot with FS Axial 4 0.4 431 70 90 340 268 218
In-phase and out-of-phase mDixon acquisitions Axial 2 Overcontiguous 5.8 First echo, 1.8; second echo, 4 15 340 196 130
T2 thick slab Radial 40 8000 800 90 200 256 205
eThrive Axial 2 1 (overcontiguous) 2.6 1.23 10 340 200 140
NoteThe use of gadolinium is optional if MRI or MRCP is performed during an acute episode or to evaluate a collection. VISTA (Philips Healthcare)= volume isotropic
turbo spin-echo acquisition, FS= fat saturation, FFE= fast-field echo, eTHRIVE (Philips Healthcare)= enhanced T1-weighted high-resolution isotropic volume excitation,
mDixon (Philips Healthcare)= modified Dixon.
aIn younger and smaller children, FOV should be decreased according to body size and the slab thickness should be no more than 2 cm.
bThe 3-T examinations were performed on an Achieva unit (Philips Healthcare) using a 16-channel torso coil (XL Coil, Philips Healthcare). For smaller children, a 6-channel

cardiac coil (Sense Coil, Philips Healthcare) can be used.

cThe mDixon sequence provides simultaneous fat and water images and in- and out-of-phase images in one breath-hold only on 1.5 T.
d The 1.5-T examinations were performed on an Enginia unit (Philips Healthcare) using a 16-channel torso coil (dS Coil, Philips Healthcare) with 16 channels anteriorly and

16 channels posteriorly. For smaller children, a 6-channel cardiac coil (Sense Coil) can be used.

more advanced or severe cases, and to no en-
hancement in cases of necrotizing pancreati-
tis (Fig. 6). The use of IV contrast materi-
al also allows the evaluation of the patency
of the adjacent vascular structures [21, 23
25]. Intrapancreatic or extrapancreatic col-
lections can also be present (Fig. 7). CT is
helpful for evaluating the presence and ex-
tent of peripancreatic collections, an early
sign of acute pancreatitis. These collections
can spread into the lesser sac and pararenal
space and even into the peritoneum and the
mediastinum [2527] (Fig. 7). Gas bubbles in
a collection are readily identified on CT and,
when present, are indicative of superimposed
infection [23, 25].
MRI and MRCP
The principle of MRCP is based on heavily
T2-weighted sequences with long TEs (range,
3001000 ms). MRCP allows visualization of
only fluid and tissues with a prolonged trans-
verse relaxation time as hyperintense struc-
tures while suppressing the background tis-
sues. MRCP is usually performed with fast
spin-echo sequences using a thick slab (2D) of
27 cm or thin-slice images with 3D capabili-
ties. Alternatively, ultrafast sequences, such as
single-shot sequences, which are acquired in
seconds, can be used in patients who are less
cooperative or patients with irregular breath-
ing. Ultrafast sequences, although less affect-
ed by motion artifact, have the disadvantage
of image blur produced by the long echo-train
length and less effective fat saturation [28, 29].
Axial T1-weighted sequences with or without
fat saturation are helpful in evaluating the nor-
mal physiologic hyperintensity of the pancre-
as (Fig. 8 and Table 1).
The MRCP technique is more challenging
to perform in pediatric patients than in adults
because it needs to be tailored to different

Fig. 3Variability of pancreatic

echogenicity on ultrasound images
of patients with acute pancreatitis.
A, Normal echogenicity and
pancreatic enlargement (P) in
9-year-old girl.
B, Diffuse increased echogenicity
with diffuse pancreatic enlargement
(P) in 12-year-old girl. Stranding
of peripancreatic fat planes and
adjacent fluid (arrows) are present.
A B

634 AJR:206, March 2016


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Fig. 4Transverse high-resolution ultrasound image
of pancreas (P) of 2-year-old boy with choledochal
cyst (asterisk) and acute pancreatitis shows
dilatation of pancreatic duct (arrow) using liver (L) as
window. Pancreatic duct (cursors) measured 3 mm.
Fig. 5Fluid collections related to acute pancreatitis.
A, Ultrasound image of pancreas obtained several weeks after episode of acute pancreatitis in 6-year-old girl shows well-defined oval fluid collection (asterisk) along
compressed pancreas (arrows).
B, Acute necrotic collection in 10-year-old girl with lupus erythematosusrelated pancreatitis. Ultrasound image of pancreas shows large heterogeneous, but
predominantly solid, collection (arrows) anterior to pancreas (P) with small fluid component (asterisk). These findings are consistent with acute necrotic collection.
AJR:206, March 2016 635
Acute Pancreatitis in Pediatric Patients
body sizes at different ages. For visualization
of small-caliber ducts, the spatial resolution
and signal-to-noise ratio need to be optimized.
These adjustments can be achieved by select-
ing a proper coil (i.e., phased-array or surface
coil) and using an appropriate slice thickness
based on the childs size (e.g., slice thickness=
35 mm in the axial and coronal planes). For
imaging neonates and infants, the slab thick-
ness should not be more than 2 cm. The ad-
ministration of secretin also increases the con-
spicuity of the smaller pancreatic ducts. The
use of a negative oral contrast agent (ferumox-
sil [GastroMARK, Mallinckrodt Medical]) or
pineapple juice, with its high iron content, de-
creases the bright signal intensity from the sur-
rounding gut, allowing better visualization of
the pancreatic duct [28, 30, 31].
The normal pancreas shows high signal
intensity on T1-weighted imaging because
of abundant aqueous proteins and intracel-
lular paramagnetic substances (i.e., man-
ganese) (Fig. 8). Adding fat suppression to
T1-weighted sequences increases the con-
trast between retroperitoneal fat and the
gland, increasing the conspicuity of the hy-
pointensity of the abnormal pancreatic pa-
renchyma (Fig. 9). As inflammation devel-
ops, the gland shows a loss of this inherent
bright signal intensity on T1-weighted im-
ages and becomes heterogeneous and hy-
pointense. After IV gadolinium admin-
istration, the normal pancreas displays
A B
homogeneous enhancement and remains
hyperintense on fat-saturated T1-weighted
images. On T2-weighted images, the signal
intensity of the normal pancreas is variable,
but it should be homogeneous and of signal
intensity similar to that of a healthy liver
(Fig. 8). On T2-weighted images, the pan-
creas becomes heterogeneous and hyperin-
tense in more advanced and severe cases of
acute pancreatitis (Fig. 9). T2-weighted se-
quences are useful for evaluating the bili-
ary and pancreatic ducts and for detecting
pancreatic and peripancreatic edema and
fluid collections. On T2-weighted sequenc-
es, even subtle pancreatic edema and peri-
pancreatic edema, which can be unapparent
on T1-weighted sequences, are more readily
identified [25, 32, 33].
In necrotizing pancreatitis, there is often
high signal intensity on T1-weighted imag-
es secondary to hemorrhage (Fig. 10). Pa-
renchymal necrosis is well depicted on se-
quential acquisitions obtained during the
first 12 minutes after the injection of gado-
linium, as shown by a lack of enhancement.
The T2-weighted sequences are most sensi-
tive for showing fluid collections; however,
it is important to be aware that fluid collec-
tions can be confused with fluid-filled bowel
loops. Gas and calcifications are more diffi-
cult to identify on this modality and are usu-
ally seen as focal areas of low signal inten-
sity on T1- and T2-weighted images [25, 33].
 Restrepo et al.
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A B C
Fig. 6Different degrees of glandular involvement in acute pancreatitis on CT.
A, Axial contrast-enhanced CT scan of 12-year-old boy with leukemia receiving l-asparaginase shows diffusely enlarged pancreas (P) with fairly homogeneous
parenchyma and mild peripancreatic inflammation (arrows).
B, Acute pancreatitis in 5-year-old girl with associated acute peripancreatic fluid collection. Axial contrast-enhanced CT scan obtained 2 weeks in disease course shows
heterogeneous pancreatic parenchyma (P) with irregular borders and fairly homogeneous hypodensities consistent with peripancreatic fluid (asterisks).
C, Axial contrast-enhanced CT scan of 8-year-old girl with necrotizing pancreatitis shows pancreatic enlargement with hypodense nonenhancing parenchyma involving
body and tail (asterisk) indicating necrosis. Compare with enhancing parenchyma of head and neck (P). Significant peripancreatic and perirenal inflammatory changes
(arrows) are present.

Role of Imaging in Pancreatitis
The utility and timing of radiologic studies
in children with suspected acute pancreatitis
remains controversial; however, imaging is part
of the diagnostic workup of acute pancreatitis
in children and helps confirm the presence of
the disease. In a 2003 analysis of studies in the
literature, which included 589 children from 18
studies, Benifla and Weizman [15] found that
the diagnosis of pancreatitis was based on ul-
trasound findings in 81% of cases. In a more
recent (2014) study by Coffey et al. [4] of 131
children, elevation of the serum lipase value
contributed to the diagnosis of acute pancre-
atitis more often than any other laboratory or
imaging test. The combination of blood and
imaging tests was shown to have an increased
diagnostic yield with at least 5% of acute pan-
creatitis cases missed if imaging had not been
performed [4]. Imaging also plays an important
role in trying to elucidate the cause of pancre-
atitis and assess the severity of the disease be-
cause the levels of pancreatic enzymes do not
necessarily correlate with the severity of pan-
creatitis [34, 35]. Finally, imaging is helpful in
evaluating for the presence of complications
and in planning potential surgical intervention
in certain cases of acute pancreatitis.
Transabdominal Ultrasound
Transabdominal ultrasound is a useful tool
and is probably the first-line imaging study
for the confirmation of pancreatitis in pedi-
atric patients with clinically suspected and
laboratory-suspected pancreatitis or in those
with inconclusive findings on clinical ex-
aminations [2, 22]. The smaller size and de-
creased amount of body fat make ultrasound
a better imaging modality for the evaluation
of acute pancreatitis in pediatric patients
than in adults. The lack of ionizing radiation,
widespread availability, and no need for se-
dation support the use of this modality in pe-
diatric patients. However, there is a lack of
studies comparing the diagnostic accuracy
of ultrasound with the diagnostic accuracy
of CT and MRI in pediatric patients [22]. In
addition, ultrasound findings are frequently
normal in pediatric patients with acute pan-
creatitis, especially in early or mild cases [2,
5, 36, 37]. Furthermore, overlapping bowel
gas due to pain-induced aerophagia or to lo-
calized ileus precludes the evaluation of the
retroperitoneal gland. In one study, the sen-

A B C
Fig. 7Intra- and peripancreatic collections in acute pancreatitis.
A, Pancreatic pseudocyst. Contrast-enhanced CT scan of 6-year-old girl (same patient as in Fig. 5A) shows well-encapsulated oval fluid collection (asterisk) along
compressed pancreas (arrows).
B, Acute necrotic collection in 10-year-old girl with lupus erythematosusrelated pancreatitis and secondary splenic artery thrombosis (same patient as in Fig. 5B). Axial
contrast-enhanced CT scan shows heterogeneous pancreatic parenchyma (P) with indistinct borders. There is large heterogeneous collection with hypodense and
hyperdense areas surrounding gland (asterisks) consistent with acute necrotic collection. Note lack of enhancement of spleen (S). St= decompressed stomach.
C, Walled-off necrosis in 12-year-old boy with acute pancreatitis diagnosed 4 weeks earlier. Axial contrast-enhanced CT scan shows well-defined oval hypodense fluid
collection (asterisk) contained within pancreatic parenchyma (P).

636 AJR:206, March 2016


TABLE 2: CT Scoring of Acute Pancreatitis According to the Balthazar
Scoring System [45]
Balthazar
Grade Description of CT Findings
A Normal findings
B Focal or diffuse enlargement of the pancreas
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C Pancreatic gland abnormalities and peripancreatic inflammation
D Fluid collection in a single location
E Two or more collections, gas bubbles in or adjacent to the pancreas, or both
aThe CT severity index is calculated by adding the points for the grade of acute pancreatitis found on CT and the
points for the degree of pancreatic necrosis (see Table 3).
sitivity of transabdominal ultrasound in de-
tecting pancreatitis was 79.4% [5].
The frequency of a biliary cause of acute
pancreatitis in pediatric patients provides the
most compelling argument for early imaging
with ultrasound [38]. Although imaging is
not a necessary part of the diagnostic work-
up for acute pancreatitis if the other two cri-
teria are fulfilled, transabdominal ultrasound
may play an important role in assessing for
biliary tract disease, one of the most com-
mon etiologic factors (e.g., calculi, chole-
dochal cyst) of acute pancreatitis in pediatric
patients [11]. Transabdominal ultrasound has
a high sensitivity (92%) in accurately detect-
ing choledochal cysts, gallstones, and pseu-
docysts [39]. Although recent advances in
ultrasound technology, such as contrast-en-
hanced ultrasound, ultrasound elastography,
and endoscopic ultrasound, have shown en-
couraging results in adult studies, these tech-
niques are still in the early stages in the di-
agnosis of pancreatic diseases in pediatric
patients [22, 37, 40, 41].
CT
CT has been shown to be more sensitive
in detecting acute pancreatitis and grading
its severity than ultrasound [39]. CT is also
more sensitive in the diagnosis of pancreatic
necrosis and fluid collections compared with
ultrasound [11]. Bowel gas is not a limitation
of CT; however, the inherent paucity of in-
traabdominal fat in children makes the eval-
uation of the organ more challenging. Other
limitations of CT are difficulty in evaluat-
ing the ductal anatomy and the use of ioniz-
ing radiation [42]. The use of CT may be of
more value later in the course of acute pan-
creatitis (i.e., if there is a lack of improve-
ment clinically), in evaluating disease severi-
ty (i.e., when pancreatic necrosis is suspected
or in cases of multiorgan failure), or if the
diagnosis is uncertain (i.e., inadequately vi-
sualized glands on ultrasound) [22, 34, 38].
AJR:206, March 2016 637
Acute Pancreatitis in Pediatric Patients
Pointsa
0
1
2
3
4 aThe CT severity index is calculated by adding the
As discussed later in this article, the CT se-
verity index (CTSI) has been shown to be a
better predictor of acute severe pancreatitis
than clinical scores in children. CT is use-
ful in identifying fluid collections and deter-
mining a suitable window if drainage is nec-
essary and in evaluating the patency of the
surrounding vessels to exclude vascular com-
plications [5, 11].
In the past, various clinical scores have
been developed to predict a complicated
course in cases with acute pancreatitis. Al-
though these scores are widely used in adult
patients with acute pancreatitis (e.g., Ramsey,
Glasgow, and Balthazar), the value of similar
scores (e.g., pediatric acute pancreatitis se-
verity [PAPS] score) has not been established
in children. The need for a reliable system to
risk-stratify children with acute pancreatitis is
underscored by the increasing number of hos-
pitalizations and high rate of major complica-
tions ( 25%) reported in recent series [2, 10,
34, 43]. The CTSI has been shown to be a bet-
ter predictor of acute severe pancreatitis than
clinical scores in children [44]. Balthazar et
al. [45] developed the CTSI, which is based
on the appearance of the pancreas and extent
of necrosis in adults. The components of the
CTSI are shown in Tables 24 [45]. The CTSI
has been reported to be superior to clinical
scoring systems in predicting the outcome of
acute pancreatitis in adults [46]. Similar stud-
ies in children have shown that CTSI is supe-
rior to clinical scoring indexes [44, 47].
TABLE 4: Complication Rates and Mortality Associated With Acute
Pancreatitis Based on CT Severity Index (CTSI) Score
Total CTSI Score Rate of Complications (%)
03 Points
46 Points
710 Points
NoteThe CTSI is calculated by adding the points for the Balthazar grade of acute pancreatitis found on CT
(Table 2) and the points for the degree of pancreatic necrosis (Table 3). Maximum CTSI score is a total of 10
points.
TABLE 3: Scoring of the Degree of
Pancreatic Necrosis on CT
Degree of Pancreatic Necrosis on CT Pointsa
Percentage of pancreas that is necrotic
0 0
< 30 2
3050 4
> 50 6
points for the grade of acute pancreatitis found on
CT (see Table 2) and the points for the degree of
pancreatic necrosis.
In children with borderline Ranson or
PAPS scores or in those with concerning
changes in clinical status (e.g., vital signs,
laboratory results, physical examination), the
CTSI may also allow clinicians to be proac-
tive in intensifying care. CT findings may
trigger the use of antibiotics in patients with
extensive necrosis, the transfer of patients at
risk for respiratory or renal failure to the ICU,
and surgical dbridement in pediatric patients
with evidence of infected necrosis. Finally,
these CT findings may lower the threshold for
initiating parenteral nutrition or enteral feeds
and may heighten the index of suspicion for
patients with fluid collections who are at risk
for pseudocyst development [34].
In a recent study including only pediatric
patients, the sensitivity, specificity, positive
predictive value, and negative predictive val-
ue of the CTSI in predicting a severe course
(using a CTSI cutoff score of>4) were 81%,
76%, 62%, and 90%, respectively, which are
better than the results of the PAPS (53%,
72%, 41%, 80%), Ranson (71%, 87%, 67%,
89%), and modified Glasgow (71%, 87%,
67%, 89%) scores. The same study showed
that, among children who underwent CT for
acute pancreatitis, the presence of necrosis
was associated with a higher rate of major
complications (mean rate of major compli-
cations in patients with necrosis vs patients
without necrosis, 42.3% vs 10.5%, respec-
tively; p= 0.002) [44].
Mortality (%)
8 3
35 6
92 17
 Restrepo et al.
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A B
Fig. 8Signal intensity of normal pancreas on MRI in healthy 12-year-old boy.
A, Axial T1-weighted image with fat saturation shows homogeneously hyperintense normal and nonenlarged pancreas (arrows). L= liver, S= spleen.
B, Axial single-shot T2-weighted image shows normal and homogeneous signal intensity of pancreas (arrows), which is similar to liver (L). S= spleen.

The CTSI may provide useful information
for risk stratification in select children with
acute pancreatitis. However, owing to the risk
of radiation exposure in children, further stud-
ies are required to determine whether chang-
es to antibiotic use, enteral or parenteral nu-
trition, ICU transfer, operative intervention, or
other clinical management strategies based on
CTSI stratification positively affect the out-
come of children with acute pancreatitis be-
fore its routine use is recommended [2].
MRCP
MRI of the pancreaticobiliary system can
overcome the disadvantages of CT in the in-
vestigation of pancreatitis, particularly in the
pediatric population. MRI has greater con-
trast resolution than CT, enabling the detec-
tion of inflammation at an earlier stage, and
this greater contrast resolution is particular-
ly useful when imaging the fat-scant pediat-
ric abdomen [42]. In addition, MRI has su-
perb capabilities (including 3D imaging)
for depicting the biliary tree and pancreatic
duct, allowing the concomitant evaluation of
the pancreatic parenchyma and its surround-
ings. Several reports in the literature sug-
gest that restricted diffusion with low appar-
ent diffusion coefficient values are seen in
acute pancreatitis even at early stages of dis-
ease [4850]. However, a more recent study
that reviewed the available data in the litera-
ture regarding the current status and recom-
mendations of DWI of the pancreas in adults
concluded that DWI had no proven role in the
diagnosis of acute pancreatitis requiring fur-
ther investigation [49]. Furthermore, the same
study reported inconsistencies and conflicting
results in the published data regarding the dif-
ferentiation between mass-forming pancreati-
tis (autoimmune pancreatitis) and malignan-
cy. MRCP is more sensitive than ultrasound
in detecting choledocholithiasis and is most
likely as sensitive as ERCP [5155]. Howev-
er, unlike ERCP, MRCP is not invasive and
poses no risk of procedure-related pancreati-
tis. According to a recent National Institutes
of Health state-of-the-science statement [56],
ERCP in acute pancreatitis should be reserved
for children in whom a biliary cause is sus-
pected or when a therapeutic intervention is

A B
Fig. 9Signal intensity of acute pancreatitis on MRI.
A, Decreased signal intensity of acute pancreatitis on T1-weighted imaging. Axial T1-weighted image with fat saturation of 10-year-old boy shows
diffusely hypointense and enlarged body and tail of pancreas (P). Compare signal intensity of pancreas with higher signal intensity of liver (L). S= spleen.
B, 9-year-old girl with pancreas divisum and acute pancreatitis. Axial single-shot T2-weighted image with fat saturation shows inflamed hyperintense
and indistinct pancreas (P) with peripancreatic edema. Pancreatic duct (straight arrow) is seen entering duodenum separate from common bile duct
(curved arrow).

638 AJR:206, March 2016

 Acute Pancreatitis in Pediatric Patients
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Fig. 10Necrotizing pancreatitis in 13-year-old boy. Axial T1-weighted image
with no fat saturation shows large hyperintense areas in enlarged pancreatic
neck, body, and tail (arrows); these findings are consistent with hemorrhage and
indicate necrosis. Compare these areas with hypointense areas of pancreatic
parenchyma in head and part of body posteriorly (asterisks).
Fig. 1115-year-old girl with gallstone pancreatitis. Axial single-shot
T2-weighted image shows intraluminal calculus inside common bile duct (straight
thin arrow) and calculi inside gallbladder (straight thick arrow). Pancreatic head
(curved arrow) is hyperintense, which indicates edema. Small amount of free fluid
(F) is present.

beneficial, such as recurrent pancreatitis or a
pseudocyst. Visualization of the pancreatic
duct and its branches can be enhanced by the
administration of secretin, which is more use-
ful in pediatric patients because the pancreat-
ic duct and its branches naturally are smaller
caliber [2830, 3638].
The major drawbacks of MRI are the long
scanning time, which requires the childs co-
operation and may result in the use of sedation,
and the higher cost. Prior studies of adults have
shown the utility of MRCP in the diagnosis of
pancreatitis in patients with pancreatic ductal
anomalies such as pancreas divisum and pan-
creatobiliary maljunction [22, 57, 58] and pan-
creatic duct disruption [26]. Shimizu et al. [59]
found MRCP to be useful as a noninvasive test
for identifying the possible causes of acute pan-
creatitis in children. MRI has been shown to
have a superior sensitivity compared with that
of CT in evaluating peripancreatic collections
[60]. MRI better delineates the internal con-
tents of a collection, important information in
determining the amenability of a collection to
drainage. Furthermore, similar to CT, MRI can
identify a safe window before drainage [60].
MRI has also been shown to play a role in as-
sessing the severity of pancreatitis, with at least
one study showing MRI to have a higher sensi-
tivity than CT for the diagnosis of acute inter-
stitial edematous pancreatitis [61].
Role of Imaging in Determining the
Cause of Acute Pancreatitis
The disorders associated with pancreatitis
in pediatric patients fall into several broad cat-
egories. The proportion of the causes of acute
pancreatitis varies greatly among studies of
acute pancreatitis in children [39, 62, 63].
The reported variation probably results
from the inherent limitations of retrospective
studies, the bias or experience of clinicians,
incomplete investigations, greater number of
patients identified to have pancreatitis, and
the recognition of new causes in children [4].
Imaging plays an additional role in eluci-
dating the etiologic mechanism of pancreati-
tis particularly in cases that result from bili-
ary, traumatic, and autoimmune causes and
will be briefly discussed.
Biliary Pancreatitis
Acute biliary pancreatitis is one of the
most common causes of acute pancreatitis in
children, comprising 1030% of all cases [6,
10, 11, 37, 43, 64]. In children, biliary pan-
creatitis has several causes such as common
bile duct obstruction by gallstones or biliary
sludge and congenital biliary tree anomalies
[65]. Obesity not only is a risk factor for cho-
lelithiasis in children but also is an indepen-
dent risk factor for the diagnosis of gallstone
pancreatitis. Therefore, obesity can be a dis-
tinguishing factor between gallstone and
sludge acute pancreatitis in children [12, 65,
66]. Cholelithiasis and sludge can be evalu-
ated using ultrasound and MRCP, which will
show filling defects in the biliary tree and
biliary tree dilatation; if performed during
an acute event, MRCP will show the pres-
ence of pancreatic inflammation (Fig. 11).
Ultrasound is the modality of choice in the
emergency setting especially in the nonobese
child. In obese children, MRCP can provide
a better evaluation of the biliary tree and
pancreas than ultrasound, thereby allowing a
more definite diagnosis. This better perfor-
mance of MRCP compared with ultrasound
is corroborated by the fact that MRCP is not
affected by the presence of bowel gas, which
frequently obscures the pancreas and distal
common bile duct [13, 14, 67, 68].
The four most common congenital pancre-
aticobiliary anomalies in the pediatric popu-
lation are pancreas divisum, choledochal cyst,
pancreaticobiliary maljunction, and aberrant
biliary ducts. Affected pediatric patients typi-
cally present early in childhood with recurrent
episodes of acute pancreatitis. Recent studies
suggest the presence of a mutation of SPINK-1
(serine protease inhibitor Kazal type 1) or of
CFTR (cystic fibrosis transmembrane conduc-
tance receptor) along with pancreas divisum
increases the risk of acute pancreatitis and ac-
counts for why only a fraction of patients with
pancreas divisum develop acute pancreatitis
[38, 58, 59] (Fig. 9B).
Congenital dilatation of the bile duct may
lead to pancreatitis as a result of concomi-
tant anomalies of the pancreaticobiliary
duct junction [6972] (Fig. 12). Therefore,
children with concomitant pancreaticobili-
ary maljunction and choledochal cysts often
present with pancreatitis, with an incidence
reported to be as high as 68% [69, 72, 73].
Congenital pancreaticobiliary anomalies are
diagnosed in children using mainly MRCP
or intraoperative cholangiography and less

AJR:206, March 2016 639

 Restrepo et al.

Fig. 12Pancreaticobiliary the arterial and venous phases on CT [85,

maljunction in 5-year-old
boy with choledochal cyst
who presented with acute
pancreatitis. Axial single-
shot T2-weighted image
with fat saturation shows
enlarged pancreatic head
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88]. Focal involvement typically presents as
a localized hypodense mass in the pancreatic
head on CT accompanied by obstructive jaun-
dice, mimicking a pancreatic neoplasm [85,
8991] (Fig. 14). On MRI, equivalent findings
to CT are seen: hypointensity on T1-weighted

with adjacent edema (curved

arrows) consistent with
focal acute pancreatitis.
Dilated common bile duct
(D) joins pancreatic duct in
center of pancreatic head
(straight arrow) indicative
of pancreaticobiliary
maljunction.
imaging and hyperintensity on T2-weighted
imaging in the areas involved and no arteri-
al phase enhancement but significant venous
phase contrast enhancement. The focal or dif-
fuse strictures of the pancreatic and bile ducts
can be well depicted on MRCP [85]. ERCP
and endoscopic ultrasound showing similar
findings may also be useful in the accurate
diagnosis of AIP.

Other Causes of Pancreatitis

frequently using ERCP. However, in patients
younger than 2 years old, visualization of
the pancreaticobiliary junction may be diffi-
cult because of its small size and, in cases of
large choledochal cysts, because of mass ef-
fect [57, 59, 67, 72].
Traumatic Pancreatitis
Trauma, both accidental and nonacciden-
tal, accounts for approximately 1040% of
pediatric pancreatitis cases [7, 9, 11, 37, 74
77]. Less common but of significant impor-
tance is post-ERCP pancreatitis [7882].
Pancreatic injuriesincluding pancreatitis
in a young child should be suspected to be
abuse-related (Fig. 13): It is estimated that
one-third of all posttraumatic pancreatitis
are nonaccidental [7882]. In the acute set-
ting, ultrasound and CT are the most helpful
techniques for confirming the cause because
of their availability in the emergency setting.
Imaging findings vary from an enlarged,
edematous, and indistinct pancreas with ad-
jacent fat stranding in cases of pancreatitis,
to a linear disruption in the gland in cases of
laceration, to complete pancreatic separation
in cases of transection [83, 84] (Fig. 13).
evated IgG4 levels among other autoanti-
bodies (antinuclear antibodies, rheumatoid
factor) in the plasma, and the typical inflam-
matory infiltrates on histopathology [87].
There are three recognized patterns of
glandular involvement in AIP, reflecting
their imaging appearance: diffuse, focal, and
multifocal. The diffuse pattern is the most
common type; it causes significant diffuse
sausagelike enlargement of the gland with in-
distinct borders but no significant peripancre-
atic fat stranding. The affected gland is hy-
poechoic on ultrasound and low density on
CT with the characteristic delayed enhance-
ment of late phases. Irregular or segmental
narrowing of the main pancreatic duct and
extrahepatic bile ducts, especially the intra-
pancreatic common bile duct, may also oc-
cur. A capsulelike hypodense rim along the
periphery of the gland has been found in both
Medication-induced pancreatitis accounts
for less than one-fourth of acute pancreati-
tis cases in children and is most common-
ly caused by valproic acid, l-asparaginase
(Fig. 6A), prednisone, and 6-mercaptopurin
in children [7, 11, 43, 64]. Systemic diseas-
es causing pancreatitis include sepsis, shock,
systemic lupus erythematous (Fig. 7B),
chronic renal failure, inflammatory bow-
el disease, cystic fibrosis, and diabetes mel-
litus [6, 9, 36, 38, 64, 9296]. A hereditary
etiologic mechanism of pancreatitis, an au-
tosomal-dominant disease, is difficult to elu-
cidate because it is nearly indistinguishable
clinically or by imaging from other causes
aside from early age of onset, with recur-
rent events occurring during the first decade
of life and most often with a family history
[97]. Although uncommon, metabolic abnor-
malities including hypercalcemia, hypertri-

Autoimmune Pancreatitis Fig. 13Nonaccidental

Autoimmune pancreatitis (AIP) is a mani- pancreatic transection
festation of an IgG4 systemic disease, which in 18-month-old boy
who presented with
is characterized by a systemic chronic fibro- abdominal distention.
inflammatory process that affects virtually Axial contrast-enhanced
every organ [85, 86]. AIP is rare, with only CT scan of abdomen
shows hypodensity in
nine cases reported in the pediatrics litera- pancreatic neck (arrow)
ture as of 2011. Hence, AIP poses a clini- with separation of
cal and radiologic diagnostic challenge. AIP pancreatic fragments
is diagnosed in a child with acute recurrent (P) consistent with
pancreatic transection.
pancreatitis or obstructive jaundice by the There is massive ascites
presence of typical radiologic findings, el- (asterisks).

640 AJR:206, March 2016


glyceridemia, diabetic ketoacidosis, and in-
born errors of metabolism, have been found
to be associated with the development of
acute pancreatitis [98100].
Complications of Acute Pancreatitis
Complications of acute pancreatitis in
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children are sterile and infected collections,
fistulas, and vascular complications. The
most common complication in pediatric pan-
creatitis is the development of pseudocysts,
which was reported to occur in 13% of pa-
tients in the analysis of studies in the litera-
ture by Benifla and Weizman [15].
Pancreatitis-Related Collections
No classification or definition of pancreati-
tis-related collections in children has been pro-
posed to date, but the complications are simi-
lar to those that occur in adults; therefore, the
Atlanta classification [101] can be useful. The
last revised Atlanta classification that includes
only adults makes a clear distinction between
the different collections and classifies them ac-
cording to whether they are associated with
acute interstitial edematous pancreatitis or nec-
rotizing pancreatitis [15, 23, 101].
Collections Associated With Acute Edematous
Interstitial Pancreatitis
Acute peripancreatic fluid collections oc-
cur in the early phase of interstitial edematous
pancreatitis. On contrast-enhanced CT, acute
peripancreatic fluid collections do not have a
well-defined wall, are homogeneous, may be
multiple, and may be confined to retroperi-
toneal fascial planes (Fig. 6B). Most of these
collections resolve spontaneously. On the oth-
er hand, pancreatic pseudocysts are a delayed
complication occurring usually after 4 weeks
of developing an acute peripancreatic flu-
id collection. Pseudocysts are the most com-
mon complication with a reported incidence
of 13% [15, 101]. Pseudocysts are thought to
arise from disruption of the main pancreatic
duct or a branch with no pancreatic parenchy-
mal necrosis, leading to a round or oval flu-
id collection with a well-defined wall in the
peripancreatic tissues (Figs. 5A and 7A). Pseu-
docysts may occasionally be partly intrapan-
creatic but should not contain solid material;
therefore, ultrasound or MRI may be required
to accurately characterize their contents [101].
Collections Associated With
NecrotizingPancreatitis
An acute necrotic collection (ANC) arises
in the first 4 weeks after development of nec-
AJR:206, March 2016 641
Acute Pancreatitis in Pediatric Patients
Fig. 14Focal
pancreatic head
involvement of
autoimmune
pancreatitis in 7-year-
old girl. Patient
presented with
obstructive jaundice.
Axial contrast-
enhanced CT scan
shows focal round
hypodensity (H) causing
pancreatic head
enlargement (arrows).
rotizing pancreatitis, either in the pancreat-
ic parenchyma or peripancreatic tissues. An
ANC contains necrotic tissue and has poorly
defined borders (Figs. 5B and 7B). The dis-
tinction between an ANC and an acute peri-
pancreatic fluid collection during the first
week of disease is difficult but becomes easi-
er thereafter by the presence of solid material
in the ANC. MRI or ultrasound can be useful
in establishing the differences. Walled-off ne-
crosis consists of necrotic pancreatic or peri-
pancreatic tissue surrounded by an enhancing
inflammatory capsule (Fig. 7C) that rarely de-
velops before 4 weeks from the onset of nec-
rotizing pancreatitis. Walled-off necrosis may
be multiple, may occur at distant sites, or may
become infected [101].
Vascular Complications of
AcutePancreatitis
Vascular complications of acute pancreati-
tis may involve the arterial or venous system
and are triggered by extravasated pancreatic
enzymes causing the loss of vessel wall integ-
rity. Arterial complications include a pseudoa-
neurysm of neighboring arteries or hemorrhage
secondary to the rupture of a pseudoaneurysm
or erosion of a major artery. In the venous sys-
tem, thrombosis is a well-known complication
that more commonly affects the splenic vein.
Pancreatic Fistulas
Pancreatic ascites and pancreaticopleural
fistulas are two uncommon types of internal
pancreatic fistulas resulting from pancreat-
ic duct disruption and subsequent leakage of
pancreatic fluid. If the pancreatic duct disrup-
tion is anterior and is not walled off, pancre-
atic ascites often develops (Fig. 13), whereas
posterior duct disruption may cause pancre-
aticopleural fistulas. The development of pan-
creaticopleural fistulas can be and more fre-
quently is the consequence of a leak from an
incompletely formed or ruptured pseudocyst
through the aortic or esophageal hiatus. These
types of fistulas usually present as persistent
or recurrent ascites or pleural effusions. CT,
MRCP, and ERCP are the current studies of
choice for the diagnosis of pancreatic ascites
and pancreaticopleural fistulas [27, 101].
Conclusion
The incidence of acute pancreatitis in chil-
dren has been increasing for the past 2 de-
cades, probably as a result of multifactorial
causes. The INSPPIRE Group [2] was formed
to standardize definitions, develop diagnostic
algorithms, investigate disease pathophysiolo-
gy, and design multicenter studies in pediatric
pancreatitis. The diagnosis of acute pancreati-
tis in children is based on clinical symptoms,
laboratory values (amylase and lipase values),
and imaging findings with two of three crite-
ria necessary to make the diagnosis. The clin-
ical presentation of acute pancreatitis in chil-
dren can be atypical, which emphasizes the
usefulness of imaging for diagnosis. Ultra-
sound is currently the first imaging modality
used in the diagnosis of acute pancreatitis in
pediatric patients. CT is reserved for imaging
sicker children who do not improve or who de-
teriorate clinically. MRI is used to elucidate
the underlying causes of pancreatitis in pedi-
atric patients.

The etiologic mechanisms of pancreatitis in
pediatric patients are varied. The most com-
mon cause is biliarymore specifically, chole-
lithiasis. A unique cause of pancreatitis in pe-
diatric patients is nonaccidental trauma, which
should be suspected in the appropriate clinical
setting. Some causes of pancreatitis, such as he-
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reditable and autoimmune diseases, may mani-
fest first during childhood but are not elucidated
until later in adulthood. Knowing the appropri-
ate terminology of collections associated with
acute pancreatitis is important for clinical man-
agement and finding the optimal time to per-
form a surgical or radiologic intervention.
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