Chest Pain in a 12-year-old

Fig. 1 via LITFL¹

What does the ECG show?

You then proceed with a detailed assessment that shows the following:

A - Self-maintaining

B - Speaking full sentences in one breath. Bilateral equal air entry with no added sounds. No chest wall tenderness or surgical emphysema.

C - Normal heart sounds with no murmur. CRT <2 seconds, with cool peripheries and normal blood pressure. Peripheral pulses present bilaterally.

D - GCS 15/15. Pupils equal (3mm) and reactive to light.

E - Abdominal tenderness noted over the right upper quadrant and, to a lesser extent, over the epigastrium. Otherwise, the rest of the abdomen is soft and non-tender with no signs of peritonism.

IV access is obtained, and blood tests are requested.

Intravenous antiemetics and analgesia are given to manage to alleviate his symptoms.

The blood results are as follows:

• WCC 16.2 x10^9/L (4 - 10)
• Neutrophils H 14.3 x10^9/L (2 - 7)
• Lymphocytes L 0.8 x10^9/L (1.1 - 3.5)
• CRP 12.4 mg/L (0 - 5)
• Amylase 1080 U/L (28 - 100)
• PT 14.8 seconds (9.4 - 13)
• INR 1.22 (0.84 - 1.16)

Bloods are otherwise normal.

What is the most likely diagnosis?

The following day he has an abdominal ultrasound, which is unremarkable. However, he remains symptomatic, and a second abdominal ultrasound reports a small amount of free fluid within the peritoneal cavity with a moderate left-sided pleural effusion.

A CT abdomen and pelvis with contrast on the same day shows left-sided pleural effusion and a small amount of abdominal free fluid, mainly in the pelvis and peri-pancreatic region, where there is also visible fat stranding. In the setting of raised amylase, the findings are diagnostic of acute pancreatitis.

A virology screen comes back negative, and cholesterol and triglycerides levels are normal. On further questioning, the child remembers that he had recently fallen off a slide and struck his abdomen.

His amylase and inflammatory markers improve during the first few days of admission with conservative management. He is followed up in clinic a few weeks later and has completely recovered.

The annual incidence of paediatric acute pancreatitis is: