Clinical and pathologic characteristics of pancreatic necrosis in critically ill children

Abstract

Abstract:

BACKGROUND: Pancreatic damage in critically ill patients is associated with the progressive failure of multiple organs, but little is known about its clinical characteristics. At present, no guidelines are available for the diagnosis and management of pancreatic damage. This study was undertaken to analyze the clinical and pathologic characteristics of pancreatic necrosis in critically ill children, and to find some biological markers of pancreatic damage or pancreatic necrosis.
METHODS: We retrospectively reviewed the clinical data, laboratory results, and autopsy findings of 25 children, who were admitted to Hunan Children’s Hospital, China from 2003 to 2009, and died of multiple organ failure. The autopsy revealed pancreatic necrosis in 5 children, in whom sectional or gross autopsy was performed.
RESULTS: The 5 children had acute onset and a fever. Two children had abdominal pain and 2 had abdominal bulging, flatulence and gastrointestinal bleeding. Four children had abnormal liver function, characterized by decreased albumin and 3 children had elevated level of C-reactive protein (CRP). B-ultrasonography revealed abnormal acoustic image of the pancreas in all children, and autopsy confirmed pancreatic necrosis, which may be associated with the damage of the adrenal gland, liver, lung, heart, spleen, kidney, intestine, thymus, mediastinal and mesenteric lymph nodes and other organs. Children 1 and 2 died of acute hemorrhagic necrotizing pancreatitis (AHNP); children 3-5 died of multiple organ dysfunction syndrome (MODS) due to pancreatic necrosis.
CONCLUSION: Pancreatic damage or pancreatic necrosis in critically ill children is characterized by acute onset, severity, short course, multiple organ damage or failure. It may be asymptomatic in early stage, and easy to be ignored.

Key words: Autopsy, Pancreatic damage, Pancreatic necrosis, Critically ill children

Yi-min Zhu, Fang Liu, Xiao-yu Zhou, Xi-rong Gao, Zhi-yue Xu, Yu-kai Du. Clinical and pathologic characteristics of pancreatic necrosis in critically ill children[J]. World Journal of Emergency Medicine, 2011, 2(2): 111-116.

Figures/Tables 3

Table 1

Figure 1.

Table 2

Pancreatic necrosis and damage of other organs in the 5 critically ill children

Child	Pathological diagnosis	Organ systems
Child	Pathological diagnosis	pancreas	adrenal gland	liver	lungs	others
1	Sepsis, acute necrotizing pancreatitis, shock, cerebral edema, pneumorrhagia	Considerable necrosis of the pancreas. Obvious necrosis of glands around pancreatic islet, little normal tissues existed Lymphocytes infiltration	Obvious vacuolar degeneration of the gland cells, several hemorrhagic necrosis	Vacuolar degeneration of several liver cells, nuclear inclusion bodies existed	Pulmonary alveoli hemorrhage, lymphocytes infiltration into interstitial tissue	Myocardial mesenchymal and endomembrane: diffuse inflammatory cells infiltration Individual myocardial cells necrosis Lymph nodes: reactive hyperplasia; immunoblast hyperplasia in follicle and lymphatic sinus
2	Still's disease, acute necrotizing pancreatitis, shock, renal failure	Necrotic foci arranging in lamellar-shape appearance of the head, body, tail of pancreas Little normal pancreatic acinar cells existed Lymphocytes infiltration, peripheral lymph nodes reactive hyperplasia	Lymphocytes infiltration into adrenal cortex and medulla	Obviously cellular edema, vacuolar degeneration, cholestasis Infiltration of lymphocytes and monocytes	Full of edema fluid in pulmonary alveoli, infiltration of lymphocytes and neutrophils into interstitial tissue	Myocardial mesenchymal: inflammatory cells infiltration Spleen: unclear structure, fibrin effusion, histiocytes and plasmacytes infiltration around blood vessels Kidney tubules: edema necrosis and abscission of epithelial cells Thyroid gland: edema and degeneration of alveoli, most of them ablated Lymph nodes: reactive hyperplasia and necrosis
3	Fulminant necrotizing hepatitis, pancreatic necrosis, congestion and necrosis of main organs (spleen, lungs, kidneys)	Obvious necrosis of the pancreas No normal pancreatic acinar cells existed Lymphocytes infiltration	No evident abnormality	Absolute necrosis of the liver, no normal hepatic lobule or bile ducts Lymphocytes infiltration	Congestion and hemorrhage, lymphocytes infiltration into interstitial tissue	Myocardial mesenchymal: lymphocytes infiltration, several vacuolar degeneration Spleen: mussy structure, hemorrhage and necrosis Lymphocytes infiltration Kidney: hemorrhage and necrosis Mesenteric lymph nodes: reactive hyperplasia
4	Malignant histiocytosis	Focal necrosis of the pancreas Lymphocytes and allotypic histiocytes infiltration	Allotypic histiocytes infiltration	Fatty degeneration of liver cells, focal necrosis of the portal area, conglobate infiltration of lymphocytes and allotypic histiocytes	Edema fluid in pulmonary alveoli, hemorrhage, allotypic histiocytes infiltration into interstitial tissue	Myocardium: lymphocytes infiltration Spleen: unclear structure, focal necrosis Allotypic histiocytes infiltration into splenic sinusoid, renal cortex, thymus gland, lymph nodes, ileocolon
5	Disseminated tuberculosis	Cheesy necrosis of the pancreas.	Cheesy necrosis and tubercular nodules	Cellular edema and degeneration, hepatic lobule disappeared, cheesy necrosis and tubercular nodules	Cheesy necrosis and tubercular nodules	Myocardium: edema Spleen and lymph nodes: cheesy necrosis and tubercular nodules

Table 2

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Child	Clinical presentation	Severe progression	Laboratory tests
Child	Clinical presentation	Severe progression	WBC ×10⁹/L	HCT %	K⁺ mmol/L	Ca²⁺ mmol/L	BG mmol/L	TB μmol/L	ALB g/L	ALT IU/L	AST U/L	LDH IU/L	BUN mmol/L	Cr μmol/L	CRP mg/L
1	Vomiting, abdominal pain, dispirited	Shock, cardiopulmonary arrest	—	—	—	—	—	—	—	—	—	—	—	—	—
2	Fever, systemic bone joint pain	Shock, cardiopulmonary arrest	16.06	20.27	4.47	2.09	6.30	8.16	28.90	54.00	84.00	386.00	4.16	43.00	68.80
3	Fever, thrombocytopenia	DIC, heart failure	15.64	25.20	4.53	2.32	—	162.20	44.10	823.00	847.60	583.00	4.72	44.00	15.90
4	Cough, fever, diarrhea	Alimentary tract hemorrhage	1.09	19.66	4.73	1.80	21.20	70.03	23.00	59.00	335.00	2264.00	5.33	47.00	—
5	Recurrent cough, fever, tachypnea	Type II respiratory failure	5.25	23.43	2.78	1.57	1.36	15.85	11.30	28.00	149.00	1737.00	5.86	65.00	127.00