In the present study, which was done on 60 children with acute pancreatitis, the number of boys (55%) was slightly higher than girls. In previous studies, the male-to-female ratio ranged from 0.9 to 1.2, which is not significantly different from the present study [2, 12–15]. The mean age of children was 8.2 years; also, other studies reported an age range of 6.9–12.5 years [2, 12–15]. In the present study, the most common clinical symptom was abdominal pain in the epigastric region (91%), followed by nausea and vomiting (80%). In other previous studies, abdominal pain (95 − 80%) was also the most common clinical symptom [10, 16, 17].
Importantly, the clinical signs of acute pancreatitis may be atypical during infancy (e.g., nausea and vomiting, fever, irritability, and abdominal distension). Therefore, it is essential to consider the diagnosis of acute pancreatitis, especially in infants with the above-mentioned unexplained symptoms. In this study, the most common causes of acute pancreatitis were systemic and metabolic diseases (35%), medications (13%), hepatobiliary diseases (10%), and infections (10%). In other studies, systemic diseases, especially diabetic ketoacidosis, sepsis, and hemolytic uremic syndrome, were the etiologies of 10–50% of cases [10, 16, 17]. In the present study, the most common systemic diseases associated with pancreatitis was hyperlipidemia.
In previous studies, medications were the cause of 10–30% of acute pancreatitis cases [10, 16–18]. The most common medications reported in previous studies were valproic acid, L-asparaginase, 6-mercaptopurine, azathioprine, steroids, mesalamine, and metronidazole [10, 15, 16, 19]. Additionally, the most common biliary cause of acute pancreatitis in the present study was choledochal cyst, while in other studies, pancreas divisum, biliary stones, and biliary stenosis were the most common anatomical causes [10, 16, 17]; the delayed diagnosis of choledochal cysts in Iran may be the cause of this difference. Corticosteroid, valproic acid, and carbamazepine were the most common causes of drug-induced pancreatitis in this study.
In the present study, no specific cause was found for acute pancreatitis in 28% of cases. The corresponding rate was estimated at 20–24% in similar studies [10, 16, 17]; this slight difference might be due to limitations in the diagnostic accuracy of modalities. Ultrasonography was performed in 88% of patients in our study; in half of the cases, the findings were consistent with acute pancreatitis. Although ultrasound is recommended as the first diagnostic method for the diagnosis of acute pancreatitis, it is operator-dependent [10, 18, 19]. An abdominal CT scan was performed for more than one-third of cases in this study. The most important indications for CT scan were necrosis, abscess, and other complications [10, 18, 19]. Given the risk of radiation exposure, the need to perform a CT scan must be carefully considered. Also, in one-third of CT scans performed in this study, no specific reason was found for the CT scans, based on the hospital records.
Adequate fluid therapy (bolus fluid infusion and intravenous fluid therapy with 1.5-2 times maintenance in the first 24–48 hours of disease) and early onset of oral nutrition play important roles in reducing the length of hospitalization and the need for ICU admission and decreasing the likelihood of disease progression into its severe form [10, 18, 19]. Only 18% of patients in the current study received bolus intravenous fluid therapy, and only half of the patients obtained more fluid than the maintenance requirement in the first 48 hours of disease; therefore, fluid therapy should be emphasized in clinical education due to its great importance in these patients.
Moreover, one-quarter of patients remained NPO after the first 24 hours, which also increased the need for further training of physicians. Almost half of the patients in this study were treated with antibiotics, and according to the hospital records, only one-third of them had indications for antibiotic treatment. According to the North American Society for Pediatric Gastroenterology Hepatology and Nutrition Pancreas Committee guidelines, administration of antibiotics for acute pancreatitis is only necessary in the case of infectious necrosis or disease progression into necrotic pancreatitis. Besides, the inappropriate use of antibiotics, along with the side effects of medications, increases the likelihood of antibiotic resistance. In this study, only one child with cerebral palsy expired, with signs of sepsis, seizures, and acute pancreatitis. According to previous studies, the mortality rate of acute pancreatitis in children is less than 5%, which is consistent with our study [10, 16, 17].
The relatively increased incidence of acute pancreatitis in our center during the COVID-19 pandemic may be related to this infection; before the pandemic, 4–5 cases of acute pancreatitis were registered every six months according to the hospital records, while after the pandemic in Iran, 11 cases were registered during six months. It seems that several viruses play an etiological role in acute pancreatitis, including mumps, measles, Epstein-Barr virus (EBV), hepatitis A virus (HAV), hepatitis E virus (HEV), and coxsackievirus [20, 21]; therefore, an association between SARS-CoV-2 and pancreatitis is probable.
Previous studies have confirmed the gastrointestinal involvement of SARS-CoV-2 . However, limited case reports have been published on the association between COVID-19 and acute pancreatitis in adult or pediatric populations during this pandemic [23–25]. The proposed pathophysiology of pancreatic involvement in COVID-19 is the expression of angiotensin-converting enzyme 2 (ACE2) in both islet cells and the exocrine portion of the pancreas[26, 27]. Pancreatic injury during an acute SARS-CoV-2 infection can be also related to indirect systemic inflammatory and immune-mediated cellular responses. Besides, antipyretics that are commonly used for COVID-19 patients can cause drug-related pancreatic damages[26, 27]. Further research is required to determine the definite effects of SARS-CoV-2 on pancreatic function and regulation.