Pancreas: Necrotizing Pancreatitis

Presentation

General

  • Pancreatic Tissue Dies Due to Inflammation & Injury
  • State of Infection:
    • Sterile Initially
    • Infected After 2-3 Weeks
    • Abscess After 5 Weeks – From Liquefication of Infected Necrosis
  • Most Common in Obese

Complications

  • Portosplenomesenteric Venous Thrombosis (PSMVT) – 50% Risk
  • Diabetic Risk After Necrosectomy: 25%
    • Risk Factors: Chronic Pancreatitis & Increased Size Resected

Hemorrhagic Signs Mn

  • Cullen Sign: Periumbilical Ecchymosis
  • Grey Turner Sign: Flank Ecchymosis
  • Fox’s Sign: Ecchymosis Over Inguinal Ligament

Cullen Sign 1

Grey Turner Sign 1

Diagnosis

Diagnosis of Necrosis

  • CT: Based on Revised Atlanta Classification
  • Revised Atlanta Classification:
    • Acute Necrotic Collection
      • ≤ 4 Weeks
      • Heterogenous Fluid Density – Some Solid Components
      • No Defined Wall
      • Intrapancreatic or Extrapancreatic
    • Walled-Off Pancreatic Necrosis (WOPN)
      • > 4 Weeks
      • Heterogenous Fluid Density
      • Well Defined Wall

Diagnosis of Infection

  • CT Showing Gas within the Necrosis (Highly Specific but Not Sensitive)
  • Percutaneous Needle Aspiration Should Be Considered for Prolonged Illness if CT is Not Specific – May Consider Forgoing if Planning to Treat Empirically & Aspiration Will Not Change Management

Acute Necrotic Collection 2

Walled-Off Pancreatic Necrosis 3

Infected Pancreatic Necrosis 4

Treatment

Sterile Pancreatic Necrosis

  • Primary Treatment: Medical Therapy (No Antibiotics Necessary)
  • Surgical Debridement:
    • Indications:
      • Failure to Thrive
      • Persistent Abdominal Pain
      • Worsening Organ Failure
    • Should Be Delayed Until 30 Days After Diagnosis
    • Mortality:
      • < 15 Days: 75%
      • 15-29 Days: 45%
      • ≥ 30 Days: 8%

Infected Pancreatic Necrosis

  • Stable: “Step-Up Approach”
  • Unstable: Antibiotics & Open Necrosectomy
    • Use Blunt Finger Dissection – Best to Differentiate Live vs Necrotic Tissue

“Step-Up Approach”

  • Approach for Management of Infected Necrotizing Pancreatitis
  • Approach:
    • Initial: Antibiotics & Drainage
      • Antibiotics: Broad Spectrum (Imipenem – Excellent Pancreatic Penetration)
      • Drainage: Percutaneous or Endoscopic Approach
    • If Fails After 72 Hours: Second Drainage Procedure or “Upsize” the Drain
    • If Fails After 72 Hours Again: Video-Assisted Retroperitoneal Debridement (VARD)
    • If Still Fails: Laparoscopic/Open Debridement
  • Delayed Debridement Reduces Mortality & Severe Complications
  • Minimally Invasive Debridement Has Lower Risk of Widespread Contamination & Systemic Complications (Diabetes/Multisystem Organ Failure)
    • Mortality Unchanged

Mnemonics

Hemorrhagic Signs in Necrotizing Pancreatitis

  • Cullen: Think “C” Around the Umbilicus
  • Grey-Turner: “Turned” to the Side
  • Fox: “Foxy” Lady in the Groin

References

  1. Wikimedia Commons. (License: CC BY-2.0)
  2. Pandiaraja J. Another cutaneous sign of acute pancreatitis. Indian J Crit Care Med. 2016 May;20(5):313-4. (License: CC BY-NC-SA-3.0)
  3. Cunha EF, Rocha Mde S, Pereira FP, Blasbalg R, Baroni RH. Walled-off pancreatic necrosis and other current concepts in the radiological assessment of acute pancreatitis. Radiol Bras. 2014 May-Jun;47(3):165-75. (License: CC BY-NC-3.0)
  4. Cunha EF, Rocha Mde S, Pereira FP, Blasbalg R, Baroni RH. Walled-off pancreatic necrosis and other current concepts in the radiological assessment of acute pancreatitis. Radiol Bras. 2014 May-Jun;47(3):165-75. (License: CC BY-NC-3.0)