Pancreatic Necrosis and Pancreatic Abscess Treatment & Management

  • Author: Alan BR Thomson, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jul 15, 2010
 

Medical Care

Evidence-based guidelines have been developed in Japan for the management of acute pancreatitis:[11]

  • Computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis;
  • infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention;
  • patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care;
  • early surgical intervention is not recommended for necrotizing pancreatitis;
  • necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis;
  • simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed;
  • surgical or percutaneous drainage should be performed for pancreatic abscess;
  • pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately;
  • pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and
  • pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.

Medical care generally is supportive, with attention paid to blood pressure and volume status.

The role of appropriate prophylactic antibiotic therapy remains controversial but has gained support in clinical practice.

Guide the choice of antibiotics by the likely flora and degree of antibiotic penetration into the abscess and the other necrotic tissue. The most commonly isolated bacteria in pancreatic abscesses are enteric organisms, through translocation through the gut. The most common pathogens are Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, and Streptococcus species.

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Surgical Care

  • Primary drainage involving an open procedure is the treatment of choice for pancreatic abscess.
  • Endoscopic sphincterotomy plays a role in patients with a dilated common bile duct from an impacted stone at risk of impending cholangitis. Surgery in acute pancreatitis is used for cholecystectomy in the patient with gallstone pancreatitis, as well as for infected pancreatic necrosis, pancreatic abscess, pseudocysts, and traumatic pancreatitis with a ruptured duct system.
  • Primary drainage of the abscess is the treatment of choice for pancreatic abscess.
  • Cases have been reported of medical treatment of pancreatic abscess in which death has not resulted; however, the standard of care is drainage involving an open procedure.
  • Case series have been reported of patients with an abscess who have been treated with CT-guided drainage tube placement, but these seem to show inferior results to open drainage. Recent advances in endoscopic treatment using EUS have made guided transgastric treatment of the complications of ANP possible. Pseudocyst drainage via the transgastric approach is now common. EUS-guided necrosectomy has been promising to date. In specialized centers, this is rapidly becoming the treatment of choice.
    • CT-guided drainage has some role in patients who cannot tolerate an open procedure. EUS with transgastric drainage is another option.
    • Consideration can be given to medical management of nonsurgical candidates until their clinical status improves.
  • Endoscopic sphincterotomy plays a role in patients with a dilated common bile duct from an impacted stone at risk of impending cholangitis. Surgery in acute pancreatitis is used for cholecystectomy in the patient with gallstone pancreatitis, as well as for infected pancreatic necrosis, pancreatic abscess, pseudocysts, and traumatic pancreatitis with a ruptured duct system.
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Consultations

  • Gastroenterology
  • General surgery
  • Interventional radiology
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Diet

  • Nothing by mouth (NPO) or a jejunal feeding tube for total enteral nutrition (TEN) is initially recommended early for ANP.
    • TEN may be used as prophylactic therapy for infected pancreatic necrosis, since it significantly decreases the incidence of pancreatic infectious complications and the frequency of multiple organ failure and mortality.
    • No contraindication for enteral feeding exists if the pancreatitis has resolved.
  • Total enteral nutrition (TEN) is superior to total parenteral nutrition (TPN) in persons with predicted severe acute pancreatitis.[12]
  • If the course is prolonged, the institution of total parenteral nutrition (TPN) can be of benefit.
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Activity

Patients generally are hospitalized and unable to perform usual activities.

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Contributor Information and Disclosures
Author

Alan BR Thomson, MD  Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Alan BR Thomson, MD is a member of the following medical societies: Alberta Medical Association, American College of Gastroenterology, American Gastroenterological Association, Canadian Association of Gastroenterology, Canadian Medical Association, College of Physicians and Surgeons of Alberta, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Eric R Frizzell, MD  Instructor of Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Department of Medicine, Division of Gastroenterology, Walter Reed Army Medical Center

Eric R Frizzell, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Jose A Perez Jr, MD, MSEd, MBA  Residency Director, Vice Chair of Education, Department of Medicine, Methodist Hospital, Houston; Associate Professor of Clinical Medicine, Weill Cornell Medical College

Jose A Perez Jr, MD, MSEd, MBA, is a member of the following medical societies: American College of Physician Executives, American College of Physicians, Society of General Internal Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Douglas M Heuman, MD, FACP, FACG, AGAF  Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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Contrast-enhanced CT scan of infected pancreatic pseudocyst.
 
 
 
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