Pediatric Pancreatitis

The pancreas is an organ that lies across the upper abdomen. It has two functions. First, it is where insulin is made. Children who develop diabetes usually do so because their pancreas quits making insulin.

The other function of the pancreas is to make digestive juices, including several enzymes. These are secreted into the gut and help break down the food you eat so it can be absorbed into your body. When the pancreas gets inflamed, these digestive enzymes escape from the pancreas and end up in the blood. The diagnosis of pancreatitis, or inflammation of the pancreas, is made if these enzyme blood levels are elevated.

The most common cause of the pancreatitis we see in the emergency department is caused by drinking an excess of alcohol. If an alcoholic comes in with upper abdominal pain, nausea and vomiting, we measure the level of lipase, one of those digestive enzymes. If it is elevated, the diagnosis is pancreatitis, and we treat the patient with IV fluids and medications for pain and nausea. The patient gets nothing to eat or drink until the symptoms have resolved.

There are many other, less common causes of pancreatitis and it can also occur in children.

One night, I was taking care of a ten-year-old boy who presented with upper abdominal pain and vomiting. We see lots of kids with abdominal pain and vomiting, usually caused by food poisoning or an intestinal virus. There was something different about this boy. He seemed sicker and his abdomen was more tender than we usually see. I ordered laboratory tests that surprisingly suggested the patient had pancreatitis. The pediatrician was called to admit the patient for treatment and further testing to determine the cause of this unusual condition.

While we were waiting for the pediatrician to come see him, I heard a commotion in the patient’s room and went to see what was going on. When I walked in, a nurse and a couple of family members were talking excitedly and hustling around the room. Sitting on the gurney was the chubby patient with a miserable, embarrassed look on his face and tears running down his red cheeks. In his lap, sat a plastic basin holding a mass of squirming, waxy-colored worms he had just vomited up.

I asked him if he had vomited worms at home. He slowly nodded his head and admitted he had flushed them down the toilet before anyone could see them.

Now, there was no reason to wonder why this boy had pancreatitis. He had recently gone on vacation to Mexico and eaten food contaminated with fertilized worm eggs. The eggs hatched into larvae, which moved through the lining of his small intestine. The larvae entered his veins and floated in the blood until they got to his lungs. They then crawled up out of his lungs into the back of his throat and were swallowed. The larvae matured and filled my patient’s guts with worms, some of which he vomited up. Others crawled up into and plugged the duct that carries the pancreatic fluids from the pancreas into his intestine. When the duct was plugged with worms, the pancreatic fluids backed up and made him sick.

The worms were mating inside him and the fertilized eggs were being passed in his stool. In unsanitary conditions, the eggs might have ended up on food that another person would eat and the lifecycle of the ascaris worms would have started over again.

Due to our first-world sanitation, we almost never see such an infection, but up to a quarter of the people in the world are affected with intestinal roundworms.

Fortunately, they are easily killed with anti-parasite medications and, most likely, the boy was going to be fine. Had he lived in a part of the world with no medical care, however, his outlook would not have been so hopeful.

Here are a couple of references if you just have to read more about intestinal worms. Enjoy!

https://en.wikipedia.org/wiki/Ascaris

http://www.medscape.com/viewarticle/410709_3

“Sweet with a bit of heat, this no-cook ice cream is a fun change from your usual ice cream sandwiches.”

When I saw this recipe in Extra, the Raley’s/Nob Hill magazine, I thought immediately of Taku Ginger Cookies, which are one of my favorites. I was a bit worried about making ice cream only from coconut milk so I replaced half of it with half and half. I gulped as I put in all that Sriracha and with good reason. I think next time I would try it with half  as much hot sauce to make them a little more subtle. Still, with the pepper kick from the ice cream and the ginger kick from the Takus, they really got right in your mouth!

Recipe By:

Nob Hill Magazine

 Yield:

18 sandwiches

Ingredients:

2 cans coconut milk, 13.5 ounces each
1 cup sugar
2 tablespoons sriracha sauce
1 teaspoon vanilla

Directions:

1. Whisk together coconut milk, sugar, Sriracha sauce and vanilla extract in a large bowl. Transfer to the bowl of an ice cream maker and freeze according to manufacturer’s instructions. Chill until firm.

2. Spoon equal amounts between ginger cookies. Freeze until firm.

Taku Ginger Cookies

Recipe adapted from:

Taku Glacier Lodge

Serving Size:

72

Ingredients:

1 cup butter, softened

1 ¾ cups sugar

¾ cup brown sugar

1 large egg

1/3 cup molasses

2 ¾ cups flour, 12.5 ounces

1 ¼ teaspoons soda

1 tablespoon cinnamon

1 tablespoon fresh ginger, peeled and grated

1 teaspoon cloves

2 teaspoons nutmeg

½ teaspoon salt

raw sugar

Directions:

1. Heat oven to 350 degrees.

2. Cream butter and sugars.

3. Add egg, ginger and molasses.

4. Mix well.

5. Combine dry ingredients except raw sugar.

6. Add flour mixture to butter mixture.

7. Mix until just combined.

8. Shape with small ice cream scoop.

9. Roll tops of balls in raw sugar.

10. Bake for about 13 minutes.

Dina is one of our PAs. She brought me a plate of fun cookies that her mother, who is Egyptian, made for me. I was really impressed with all the work to make so many different kinds. When I make cookies, I only make one kind at a time. These were very interesting to look at and fun to eat as well.

Quincy is an outdated name for a peritonsillar abscess.* This is an infection with a pocket of pus in the back of the throat, under one of the tonsils. People with a peritonsillar abscess have a very bad sore throat, fever and difficulty swallowing. It is really a miserable thing to endure.

When such patients come into our emergency department, we start an IV, through which we give them fluids, pain medicine and antibiotics. We then drain the pus out of the abscess, either by sucking it out with a big needle or cutting it open with a scalpel.

I had never really thought, before, about what might happen to a patient with a peritonsillar abscess if there were no one like me around to provide any care. I got insight into that when I was reading an account in a life history written by my great-grandfather, George Arthur Hurst. The event happened when he was twelve years old. I offer it not as a testimony that God answers prayers. Rather, I share it to offer insight into what illness was like when people had no access to medical care.

“In the summer of 1883, my mother was very ill with Quinsy. She had not eaten a morsel of food for fourteen days, as her throat was so badly swollen that she could not swallow. Father was away on a business trip. My older sister, Luell, had gone on a visit. I was the oldest child at home and was trying to do something to relieve Mother’s suffering.

“I felt I needed help. I went out in the orchard where I knew I was alone and kneeled down and poured out my heart to my Heavenly Father and asked him to come to our assistance and relieve Mother’s suffering, if it was his will.

“I arose, feeling much lighter hearted, knowing that my prayer had been heard and would be answered.

“I had no sooner reached the house when the baseness in Mother’s throat broke with such a gush that it nearly strangled her. I grabbed a small wash bowel and handed it to her. There was half a bowl full of puss and blood ran from her mouth and nostrils. As soon as she could clear her throat enough to talk, she told me to make a fire and cook a bowel of cornmeal gruel for her, which I did, then added a little new milk and gave her to drink. With some difficulty she drank the gruel and in about ten minutes she dropped off to sleep and did not awake until late morning.

“Can you make me think this was not a direct answer to my fervent and humble prayer!”

From George Arthur’s description, it is obvious that the abscess finally grew so large that it burst, allowing the pus to escape. Only then was his mother able to swallow. Thank goodness we have access to medical care so we don’t have to suffer like this.

* https://en.wikipedia.org/wiki/Peritonsillar_abscess

Here is the last of the Six Sisters’ Stuff recipes I got from my mother in law. This is pretty much right off their website. I found it a bit tricky to roll the chocolate dough around the filling. I was working on a warm day and found it  easier when I refrigerated the dough and filling for a while.

As far as chunky vs. creamy peanut butter, I can’t imagine it makes any difference. When Shari and I got married, she came from a crunchy family and I came from a creamy family. I was not interested in converting and recommended that we just have both kinds. Rather than do that, Shari converted and we raised our kids in a creamy family so all is well with the world.

Recipe By:

Six Sister’s Stuff

Yield:

30

Ingredients:

1 ½ cups all-purpose flour
½ cup unsweetened cocoa powder
½  teaspoon baking soda
¼ teaspoon salt
½ cup granulated sugar,  plus extra for dredging
½ cup brown sugar
½ cup butter, softened
¼ cup smooth peanut butter
1 teaspoon vanilla extract
1 large egg
1 large egg yolk
¾ cup peanut butter, crunchy or smooth, your choice
¾ cup confectioners’ sugar

Directions:

1. Heat oven to 375°F.

2. Lightly grease (or line with parchment) two baking sheets.

3. In a medium-sized bowl, whisk together flour, cocoa, baking soda and salt. Set aside.

4. In another medium-sized mixing bowl, beat together sugars, butter, and ¼ cup peanut butter until light and fluffy.

5. Add vanilla, egg and egg yolk. Beat to combine.

6. Stir in dry ingredients, blending well. Set aside.

7. Make the filling in a small bowl by stirring together ¾ cup peanut butter and confectioners sugar until smooth.

8. With floured hands or a small cookie scoop, form the filling into 26 one-inch balls.

9. Scoop 2 tablespoons of dough (a lump about the size of a walnut), make an indentation in the center with your finger and place one of the peanut butter balls into the indentation. Bring the cookie dough up and over the filling, pressing the edges together to cover the center. Roll the dough ball in the palms of your hand to smooth it out. Repeat with the remaining dough and filling.

10. Roll each rounded cookie in granulated sugar. Place on prepared baking sheets, leaving about 2 inches between cookies. Grease the bottom of a drinking glass and use it to flatten each cookie to about ½ -inch thick.

11. Bake 7 to 9 minutes, or until they’re set and you can smell chocolate. Remove from the oven and cool on a rack.

At 6:45 am, just when things should be tied together for the end of my shift, medics brought in a ten-year-old girl having a seizure. Her mother and the paramedics had both given her emergency medication but she was still seizing, though not violently.

Before I could even evaluate the patient, the mother approached me to say her daughter had a long history of seizures. She said she had with her a letter from their pediatric neurologist saying the patient should be given 20 milligrams per kilogram of phenobarbital in situations like this. Information from family is always helpful. It helps guide, but never overrides, my best judgment on how to care for patients. In this case, I reassured mom we would give her daughter that medication as soon as we had an IV line in place. Mom told me she was going up to the inpatient pediatric unit to “get help.” “Oh well,” I thought as she disappeared.

Our excellent nurses quickly placed two IV lines so, without delay, we were able to give the child 2 milligrams of lorazepam intravenously. This fast-acting medication stopped the seizure. Once that was controlled, we discovered the child also had a high fever, so I ordered all the tests we normally do on someone with uncontrolled seizures as well as those to find out why she had a fever.

By this time, the mother returned, apparently frustrated in her efforts to rally help from the people on the pediatric unit. She immediately tried to take control of the situation in the emergency department. She refused to let us put in a urinary catheter so we could collect and check her daughter’s urine for a urinary track infection. She demanded that one of the two IVs be removed. She refused to let one specific nurse provide care, etc. Her understandable concern for her daughter was disrupting the care her daughter needed.

I took mom aside and made her look directly at me. Then, in a calm voice, I pointed out her daughter stopped seizing after the medicine we gave her and I explained what else we were doing to take care of her. Mom argued that the lorazepam would not last for long. In reply, I pointed out the nurse who, at that very moment, was giving the longer-lasting phenobarbital she had told me the patient needed. With that, Mom seemed to relax somewhat.

I updated the day shift doctor on the case and went to finish up my charting. From the nurses’ station, I heard the mother get so out of hand my partner threatened to remove her from the emergency department if she didn’t calm down. In response, mom called the police on him.

Records showed that this mother had done similar things during previous hospital stays including calling the police to report nurses and doctors. People had spent time helping her see the effect her behavior might have on care providers. It obviously didn’t work because the mother resorted to the same behavior the morning I was in charge of her daughter’s care.

It is hard to imagine how difficult it is for parents to deal with stressful, long-term situations like this. You learn by experience what works for your child. And because you would do anything necessary, you can’t stand someone doing things different than what you would do. Your love and frustration drive you to take control of situations even when that causes problems for those caring for your loved one. You just want your child to be safe and normal, and you would do anything to make that happen. (In this situation, we later found out the child had been taken to China for experimental stem cell injections in an effort to cure her seizures.)

As I walked through the emergency department on my way out, the mother approached me in the hall and took time to thank me. She told me I was the first doctor to ever listen to her. I found that amusing and it made me feel good though I doubted it was true.