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BACKGROUND: Acute pancreatitis is observed more frequently in the pediatric age. Currently, there are recommendation guidelines for its proper diagnosis and treatment. The objective of this study was to evaluate the level of knowledge of the international recommendations on acute pancreatitis in pediatrics of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition in a group of pediatricians. METHODS: Observational, multicenter study, through a survey applied to pediatricians and pediatric residents. RESULTS: 48.8% of physicians had prior knowledge of the guidelines for the treatment of acute pancreatitis in children. 72.4% knew the current criteria for the diagnosis of acute pancreatitis. There were no differences in the majority of responses between pediatricians and pediatric residents. CONCLUSIONS: Although only half of the respondents followed the guidelines for diagnosis and treatment of acute pancreatitis, about three-quarters adequately use the criteria for diagnosis. There is adequate knowledge about the prescription of antibiotics and pancreatitis follow-up. There is lack of knowledge on the recommendation of monitoring vital signs and the precise time to perform cholecystectomy in the pancreatitis of biliary origin.

INTRODUCCIÓN: La pancreatitis aguda se observa con mayor frecuencia en la edad pediátrica. Actualmente existen guías de recomendaciones para su adecuado diagnóstico y tratamiento. El objetivo de este estudio fue evaluar el nivel de conocimiento de las recomendaciones internacionales sobre pancreatitis aguda de la North American Society for Pediatric Gastroenterology, Hepatology and Nutrition en un grupo de pediatras. MÉTODOS: Estudio observacional, multicéntrico, mediante una encuesta aplicada a médicos pediatras y médicos pediatras en formación. RESULTADOS: El 48.8% de los médicos tenían conocimiento de las guías para tratamiento de pancreatitis aguda en niños. El 72.4% conocían los criterios actuales para el diagnóstico de pancreatitis aguda. No hubo diferencias en la mayoría de las respuestas entre médicos pediatras y médicos pediatras en formación. CONCLUSIONES: Aunque solo la mitad de los encuestados conocían la guía para el diagnóstico y el tratamiento de la pancreatitis aguda, cerca de tres cuartas partes utilizan adecuadamente los criterios para el diagnóstico. Existe adecuado conocimiento sobre la prescripción de antibióticos y el seguimiento posterior a la pancreatitis aguda. Hay déficit en el conocimiento sobre las recomendaciones de la monitorización de los signos vitales y el momento adecuado para realizar la colecistectomía ante una pancreatitis de origen biliar.

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Early enteral nutrition through a feeding tube is essential for the management of severe acute pancreatitis (SAP). Nasojejunal tube nutrition has been preferred on the assumption that it provided pancreatic rest in comparison to the nasogastric tube. However, nasojejunal tube placement is complex, may delay feeding initiation and can increase hospital costs. Our aim was to compare the efficacy and safety of enteral feeding with a nasogastric tube versus nasojejunal tube in patients with SAP. We searched four databases (PubMed, Web of Science, Scopus, and Embase) until December 1, 2022. We included randomized controlled trials (RCTs) comparing enteral feeding by nasogastric and nasojejunal tubes in patients with SAP. Primary outcome was all-cause mortality. Secondary outcomes were organ failure, infection, complications, surgical intervention, duration of tube feeding and length of hospital stay. Risk of bias assessment was completed independently by two investigators using the Cochrane RoB 2.0 tool. We performed random effects model meta-analyses using the inverse variance method. Effect measures were reported as relative risks (RR) and their 95% CIs for dichotomous outcomes and mean differences (MD) and their 95% CIs for continuous outcomes. We included four RCTs involving 192 patients with SAP. The mean ages ranged between 36 and 62 years old. There was no significant difference in all-cause mortality between the nasogastric and nasojejunal feeding arms (18/98 vs. 23/93; RR 1.34, 95%CI 0.77-2.30; p=0.30). There were no significant differences in all secondary outcomes between feeding arms. There were three RCTs with some concerns of bias, in the randomization process. In conclusion, in patients with SAP, enteral feeding delivered by nasogastric tube was as efficacious and safe as nasojejunal tube. Further randomized controlled trials with more participants and better design are needed to confirm these findings.

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This article summarizes the clinical practice guideline (CPG) for the management of acute pancreatitis in the Social Security of Peru (EsSalud), to provide evidence-based clinical recommendations for the management of acute pancreatitis in EsSalud. A guideline development group (GEG) was formed that included medical specialists and methodologists. The GEG formulated 7 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and -when considered relevant- primary studies were carried out in PubMed during 2022. The evidence was selected to answer each of the clinical questions posed. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the GEG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice, and the corresponding flow charts. Finally, the CPG was approved with Resolution No. 105-IETSI-ESSALUD-2022. This CPG addressed 7 clinical questions on fluid therapy, start of enteral nutrition, analgesia, type of nutrition, antibiotic, and surgical treatment. Based on these questions, 8 recommendations (1 strong and 7 conditional), 13 BPCs, and 1 flowchart were formulated. This article summarizes the methodology and evidence-based conclusions of the CPG for the management of acute pancreatitis in EsSalud.

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Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.

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INTRODUCTION AND AIM: Acute pancreatitis (AP) is the most common cause of pancreatic disease in children. Previous studies have described factors related to days of hospital length of stay (LOS) in children. Our aim was to identify factors associated with LOS in AP. MATERIALS AND METHODS: A retrospective study was conducted at the Hospital Infantil de México Federico Gómez in Mexico City, encompassing the time frame of January 1, 2017 and March 31, 2019. AP was confirmed by medical chart review, according to the INSPPIRE criteria at the time of hospital admission, in patients below 18 years of age. AP grade was classified, following the NASPGHAN guidelines. Demographic, clinical, biochemical, nutritional, and treatment data were collected. Prolonged hospital LOS was considered that which lasted 7 days or longer. RESULTS: Fifty-one events (32 patients) were registered. Median LOS was 8 days (IQR 4-14 days). Antibiotic use was significantly associated with longer LOS (OR 31.71; 95% CI: 2.71-370.65; p = 0.006) and early feeding (EF) (within 72 h of admission) was associated with shorter LOS (OR 0.05; 95% CI: 0.001-0.63; p = 0.02). There was no association between LOS and the variables of age, recurrence, grade, etiology, comorbidities, complications, fluid resuscitation, parenteral nutrition, or biochemical characteristics upon admission. CONCLUSION: Our study, like others, corroborated the fact that EF in the management of AP was associated with fewer days of hospital LOS.

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La pancreatitis aguda es la inflamación del páncreas que se caracteriza por dolor abdominal epigástrico intenso y persistente con niveles elevados de enzimas pancreáticas en la sangre (1, 2). La pancreatitis aguda tiene una incidencia anual que varía de 4.9-73.4 casos por 100 000 habitantes a nivel mundial (3) y es la enfermedad gastrointestinal más común de los pacientes que se hospitalizan en los Estados Unidos (más de 270 000 casos que generan costos anuales de hasta 2.6 mil millones de dólares) (4, 5). En el Perú, se ha registrado una incidencia anual de pancreatitis aguda de 28 casos por cada 100 000 habitantes durante el 2009 (6). La causa más común de la pancreatitis aguda es la litiasis biliar (75%) (7), mientras que el alcoholismo causa aproximadamente una cuarta parte de los casos (8). Otras etiologías identificadas son la hipertrigliceridemia, la pancreatitis aguda post colangiopancreatografía retrógrada post-endoscópica (CPRE), causas genéticas, medicamentosas o por lesión traumática. La severidad de la pancreatitis aguda debe evaluarse mediante un examen clínico identificando pérdidas tempranas de líquidos, insuficiencia orgánica (cardiovascular, respiratorio o renal) o síndrome de respuesta inflamatoria sistémica. Según la clasificación de Atlanta (9), se puede dividir en leve, moderada-severa o severa (10-12) (tabla 2). El pronóstico de severidad en la PA se basa en datos clínicos, laboratoriales y/o radiológicos (13- 17), los cuales se han agrupado en sistemas de puntuación útiles para determinar el índice de severidad en pancreatitis aguda como el "Bedside Index for Severity in Acute Pancreatitis" (BISAP) (18) y el índice de severidad tomográfica (19) (tabla 2). La evaluación y el manejo adecuados de los casos de pancreatitis aguda pueden reducir la mortalidad y las complicaciones de esta condición. Por ello, el Seguro Social de Salud del Perú (EsSalud) priorizó la realización de la presente guía de práctica clínica (GPC) para establecer lineamientos basados en evidencia para gestionar de la mejor manera los procesos y procedimientos asistenciales de la presente condición. Esta GPC fue realizada por la Dirección de Guías de Práctica Clínica, Farmacovigilancia y Tecnovigilancia del Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) de EsSalud.

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Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors' own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric-rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

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El síndrome de quilomicronemia familiar (SQF) es unaenfermedad autosómica recesiva rara, con una prevalencia1:200 000 - 1:1 000 000, y se caracteriza por quilomicronemiaen ayunas y niveles muy elevados de triglicéridos (> 880 mg/dl). LPL es el gen más frecuentemente afectado, luego APOC2,GPIHBP1, APOA5 y LMF1; todos ellos comprometen la función de la lipoproteinlipasa endotelial. El SQF suele presentarseen la infancia con dolor abdominal recurrente, xantomaseruptivos, retraso del crecimiento, pancreatitis y, en ocasiones,asintomático. El tratamiento convencional es la restriccióndietética de grasas. Se muestra el resultado clínico de 20 pacientes pediátricoscon SQF reclutados de 4 hospitales en Argentina.

Familial chylomicronemia syndrome (FCS) is a rare autosomalrecessive disease, prevalence 1:200,000 - 1:1,000,000, andis characterized by fasting chylomicrons and very hightriglycerides > 880 mg/dl. LPL is the most frequentlyaffected gene, then APOC2, GPIHBP1, APOA5, LMF1, all ofthem compromising the function of lipoproteinlipase. FCScommonly presents in childhood with recurrent abdominalpain, eruptive xanthomas, failure to thrive, pancreatitis, andsometimes asymptomatic. The conventional treatment isdietetic fat restriction. The clinical outcome of 20 pediatric patients with FCS recruited from 4 hospitals in Argentina is reported.

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