Severe Acute Necrotizing Pancreatitis – Case Report

Abstract

Background

Acute necrotizing pancreatitis is a severe form of pancreatitis. It is confirmed with an MRI (MRCP) or IV contrast CT, which shows that more than 30% of the pancreas is not enhanced. A prompt diagnosis of necrotizing pancreatitis is important because it has implications in morbidity and mortality. Treatment of the necrotizing type is different compared to the interstitial pancreatitis. More often than not, patients with necrotizing pancreatitis appear unwell, in shock or in multiple organ failure. The decision when and what type of surgery is needed for necrosis debridement, should be made by the pancreatic surgeon, after discussions with gastro-enterologists.

Case presentation

The patient was surgically treated for acute cholecysto-pancreatitis with empyema and peritonitis. For 10 days he was treated at the hospital, but was not improving. He presented signs of septic shock, hypotension, fever, leucocytosis and purulent discharge from abdominal drains. After initial resuscitative measures, it is concluded the patient need and urgent laparotomy for necrosis debridement. One month after the necrectomy and multiple drainage procedure the case is complicated by bile leak after the removal of a T-tube. Failure of ERCP prompted a reintervention for the surgical placement of a common bile duct stent. The patient recovered well and was discharged from the hospital.

Discussion

Patients diagnosed with acute pancreatitis should be looked up finding the possible cause. 50-60% of the incidence is due to gallstones or related problems. Approximately 20% of the cases are caused by alcohol intake and the rest have an idiopathic etiology. The first step in managing acute pancreatitis is fluid and electrolyte rehydration, maintaining adequate systemic circulation. Antibiotic treatment is a controversial topic regarding the timing. Antibiotic use has shown benefit when administered early in patients with necrotic pancreatitis. There is an ongoing debate if the patient should be kept nil per or should continue enteral nutrition as tolerated. However nutritional support is an important component, as catabolic states are associated with higher mortality.

Conclusion

It is generally recommended that sterile necrotic pancreatitis is treated conservatively with early antibiotics. Meanwhile, patient with infected necrosis should be treated surgically, via endoscopy, laparoscopy, percutaneous drainage or open surgery.

Keywords: General Surgery, Acute Pancreatitis, Necrotizing Pancreatitis, Debridement.

DOI: 10.7176/JEP/14-16-02

Publication date:June 30^th 2023