Necrotizing Pancreatitis

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Necrotizing Pancreatitis

• Donald Baril
• Department of Surgery Grand Rounds
• Elmhurst Hospital Center
• February 25, 2004

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Epidemiology

• ? 185,000 cases of acute pancreatitis/year in
  U.S.
• ? Gallstone pancreatitis accounts for 40-80 of
  cases
• ? Necrosis present in 20-30 of all cases
• ? Most common between the ages of 50 and 70
• ? Presence of necrosis increases morbidity and
  mortality rates from 23 to 82 and lt1 to 10
  respectively

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Etiology

• ? Gallstones
• ? Alcohol abuse
• ? Endoscopic retrograde cholangiopancreatography
• ? Hyperlipidemia
• ? Drugs
• ? Pancreas divisum
• ? Abdominal trauma

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Pathophysiology

• ? Disruption in the normal separation of
  lysosomal and pancreatic enzymes which leads to
  the exposure of pancreatic proenzymes to
  lysosomal enzymes leading to pancreatic
  autodigestion
• ? Biliary pancreatitis
• ? obstructing stone at ampulla allows bile to
  reflux into the pancreatic duct
• ? obstructing stone at ampulla produces
  pancreatic duct hypertension

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Presentation and Diagnosis

• ? History Epigastric pain, nausea/vomiting,
  fever
• ? Physical exam fever, tachycardia, epigastric
  tenderness,
• Grey-Turners sign, Cullens sign
• ? Laboratory values elevated amylase and lipase,
  leukocytosis,
• elevated liver function tests

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Radiographic studies

• ? Abdominal x-ray
• ? typically nonspecific
• ? may exclude other causes of abdominal pain
• ? may show a sentinel loop or a colon cutoff
  sign
• ? Ultrasound
• ? typically shows a diffusely enlarged,
  hypoechoic pancreas
• ? sensitivity of 67 and near 99 specificity
  in
• the diagnosis of acute
  pancreatitis
• ? MRCP

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Colon cutoff sign
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Radiographic studies CT scan

• ? CT (contrast-enhanced)
• ? gold standard for the noninvasive diagnosis
  of necrotizing pancreatitis
• ? affected portions fail to enhance secondary
  to disruption of the normal pancreatic
  microcirulation
• ? accuracy of gt 90 when at least 30
  glandular necrosis is present

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Severity of pancreatitis based on CT findings
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(No Transcript)
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CT findings of necrotizing pancreatitis
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CT findings of necrotizing pancreatitis
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CT findings of necrotizing pancreatitis
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Endoscopic retrograde cholangiopancreatography

• ? Gold standard to diagnose choledocholithiasis
• ? Should be used in combination with
  sphincterotomy for patients with severe gallstone
  pancreatitis and suspected persistent biliary
  obstruction
• ? Carries inherent risks of exacerbating the
  ongoing pancreatitis and introducing infection
  into sterile necrosis

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Management aims

• ? Two phases of acute pancreatitis
• ? Initial 14 days characterized by the systemic
  inflammatory
• response syndrome (SIRS)
• ? intensive medical support
• ? prevention of infection
• ? Infection of pancreatic necrosis which occurs
  in the second
• and third week following the onset of
  symptoms
• ? treatment of local infectious complications
• and debridement

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Infected necrosis

• ? 30-70 of patients with acute necrotizing
  pancreatitis develop local pancreatic infection
• ? Mortality triples in the presence of infection
  from 10 to 30
• ? Risk of infection increases with the amount of
  necrosis and the time from onset of pancreatitis
• ? 24 of pts have bacterial contamination at
  1week
• ? 71 of pts have bacterial contamination at
  3weeks
• ? greatest risk in pts with gt50 necrosis

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Infected necrosis

• ? Sources of infection include bacterial
  translocation from the colon, hematogenous
  spread, descending infection via the biliary duct
  system, or ascending via the duodenum
• ? Organisms
• ? Escherichia coli, Pseudomonas, Klebsiella,
  Enterococcus, Proteus, Bacteroides
• ? Streptococcus faecalis, Staphylococcus
  aureus
• ? Candida species

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Prevention of bacterial infection

• ? Enteral feeding
• ? avoids central line-related infections
• ? maintains gut barrier integrity
• ? decreases bacterial translocations
• ? Selective decontamination of the gut with
  non-absorbable antibiotics
• ? Prophylactic systemic antibiotics
• ? Imipenem remains the antibiotic of choice
• ? Quinolones in combination with Metronidazole
  are the
• second-line agents

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Determination of infected necrosis

• ? CT or ultrasound guided fine-needle aspiration
  of pancreatic necrosis is performed in patients
  with known necrosis who develop clinical signs of
  sepsis
• ? sensitivity of 96 and specificity of 99
• ? complications include risk of secondary
  infection, bleeding, and aggravation of
  acute pancreatitis

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Indications and timing of surgery

• ? Benefit of surgery in patients with sterile
  necrosis remains unproven but should be pursued
  in cases with MSOF unresponsive to medical
  treatment
• ? Infected necrosis is a clear indication for
  surgery
• ? Surgical intervention should be postponed as
  long as possible
• ? demarcation between viable and necrotic
  tissue is
• more clearly defined
• ? decreases the bleeding risk
• ? minimizes surgery-related loss of vital
  tissue

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Goals of Surgical Interventions

• 1) Removal of pancreatogenic exudate from the
  peritoneal cavity and lesser sac
• 2) Removal of infected, necrotic pancreatic and
  peripancreatic tissue
• 3) Preservation of viable pancreatic tissue
• 4) Postoperative evacuation of remaining debris
  and exudate

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Surgical Interventions

• 1) Necrosectomy with open packing
• ? mortality of 15-17
• ? pancreatic fistula rate of 26-46
• 2) Necrosectomy with closed packing
• ? mortality of 6.2
• ? pancreatic fistula rate of 9
• 3) Necrosectomy with closed continuous lavage of
  the retroperitoneum
• ? mortality of 21
• ? pancreatic fistula rate of 19

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Percutaneous drainage

• ? Generally fails to be curative but may be
  beneficial in stabilizing septic patients
• ? Single study utilizing large bore drainage
  catheters (28 French) avoided surgery in 47 of
  pts (16/34) with infected pancreatic necrosis

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Complications of necrotizing pancreatitis

• ? Persistent or recurrent infection
• ? Postoperative hemorrhage
• ? Pancreaticocutaneous fistula
• ? Enterocutaneous fistula
• ? Duodenal obstruction
• ? Pancreatic insufficiency

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Conclusions

• ? Necrotizing pancreatitis continues to have
  significant morbidity and mortality despite
  advances in medical therapy
• ? Patients with necrotizing pancreatitis should
  all receive antibiotic prophylaxis
• ? Surgery should be delayed as long as possible
  and has no proven role in sterile necrosis