Pancreatic necrosis and Pancreatic Abscess

In the characterization of infections in the pancreas,

recognizing the different terms used in describing this
complication of acute pancreatitis is important
 Pancreatic necrosis and Pancreatic Abscess
General Consideration
Pancreatic abscesses form through various
mechanisms including: ▼

► penetrating peptic ulcers and

► secondary infection of pseudocysts

At any point after the initial injury in acute necrotizing

pancreatic (ANP), ►infection of necrotic tissue may
occur ► leading to abscess formation
Pancreatic necrosis and Pancreatic Abscess

General Consideration
► A pancreatic abscess (PA) is a collection of pus
resulting from tissue:
necrosis
liquefaction and
infection

► Infected necrosis refers to bacterial contamination of

necrotic pancreatic tissue in the absence of abscess
formation
 Pancreatic necrosis and Pancreatic Abscess

General Consideration
The most typical organisms isolated from infected:
necrosis and abscesses are:
enteric bacteria and
Candida species

►There no evidence that prophylactic antibiotics given

early in the course of acute pancreatitis decrease the
incidence of abscess
Pancreatic necrosis and Pancreatic Abscess

►A pseudocyst is a peripancreatic fluid collection

containing high concentrations of pancreatic
enzymes within a defined fibrous wall and lacking
an epithelial lining
Pancreatic necrosis and Pancreatic Abscess

Pancreatic abscess is a late complication of acute

necrotizing pancreatitis (ANP), occurring more than
4 weeks after the initial attack

The mortality rate associated with pancreatic

abscess is generally less than that of infected
necrosis
Pancreatic necrosis and Pancreatic Abscess
Pathophysiology:
Remember:
ANP is the most severe end of a spectrum of
inflammation associated with pancreatitis

► Inflammation causes cell death with resultant

devitalized tissue, which is likely to become infected

► The amount of necrotic tissue is the strongest

predictor of mortality in ANP
Pancreatic necrosis and Pancreatic Abscess
Pathophysiology:
After pancreatic necrosis occurs, 3 potential outcomes
exist:
1. resolution
2. pseudocyst or
3. abscess

Pseudocysts and abscesses can be:

single or
multiple and
vary greatly in size
Pancreatic necrosis and Pancreatic Abscess

Sex
Differences in sexual predilection are based on the
difference in frequency of causative factors of the
pancreatitis

Causes:
► cholelithiasis and
► alcohol
account for more than 80% of cases in the developed
world
Pancreatic necrosis and Pancreatic Abscess
Causes
Superinfection of pseudocysts is one way that pancreatic
abscesses may form though pseudocysts are not a
prerequisite for abscess formation

►Evidence suggests that colonic translocation of

bacterial flora accounts for many cases of pancreatic
infection
Clinical findings
History
► hemodynamic instability

► fever (39-40 C)

► failure of medical therapy or

► the presence of fluid collections on CT scan and

► WBCC 15-20.000/µL
 Pancreatic necrosis and Pancreatic Abscess

Clinical findings
Physical
Pain
epigastric pain
tenderness and
a palpable tender mass
are the principal clues to diagnosis

Vomiting or jaundice
may be present
 Pancreatic necrosis and Pancreatic Abscess

Lab findings
Serum amylase
May be elevated, but usually is normal

Serum albumin
Is below 2-5g/dL ( normal: 3.4-5.4)

Alkaline phosphate is elevated

 Pancreatic necrosis and Pancreatic Abscess

Imaging Studies
Pleural fluid and diaphragmatic paralysis may be
evident on chest x-rays

An upper gastrointestinal series usually shows

deformity of the:
stomach or
duodenum
by a mass
 Pancreatic necrosis and Pancreatic Abscess
Clinical findings
Diagnostic
ultrasound or
CT scanning
will usually indicate the presence of a cyst in the
area of the pancreas

The distinction between:

nonifected pseudocyst and
pancreatic abscess
depends on clinical evidence of suppuration
•
 Pancreatic necrosis and Pancreatic Abscess

Clinical findings
In about 10% of cases, a plain film of the abdomen
will reveal gas bubbles (“soap bubble sign”) in the
area of the pancreas, a diagnostic finding

In general the diagnosis is difficult, treatment is

often instituted late, and morbidity and mortality
rate are high
 Pancreatic necrosis and Pancreatic Abscess
Complications

Fistula formation
Enterocutaneous
Entero-entero
Enterovascular

Recurrent pancreatitis
Bowel obstruction
Treatment
Medical Care:
Medical care generally is supportive, with attention paid to:
blood pressure and
volume status

Because patients frequently are transiently bacteremic,

antibiotics are routinely administered
Treatment
Surgical Care
Primary drainage of the abscess is the treatment of
choice for pancreatic abscess

The standard of care is drainage involving an open

procedure
 Treatment
Surgical Care
The goals of operative treatment are to:
1)
remove devitalized
pancreatic and
peripancreatic tissues

2)
evacuate all purulent material and
provide continuous drainage
Treatment
Surgical Care

CT, or US-guided percutanuous drainage

Marsupialization
Pancreatic necrosis and Pancreatic Abscess

Prognosis
The mortality rate is about 30%, a consequence of:
*the severity of the condition and
*the inability in some cases to make the diagnosis
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