Pancreatic Necrosis and Pancreatic Abscess Workup

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

Laboratory Studies

  • No specific hematologic studies define infected necrosis or pancreatic abscess.
  • A persistently elevated white blood cell count with a left shift and positive blood cultures is suggestive of this diagnosis.
  • The degree of pancreatic enzyme elevation does not directly indicate the degree of necrosis.
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Imaging Studies

  • The presence of air in necrotic tissue in a pseudocyst on imaging studies is specific for infection as well.
  • Abdominal CT scan with IV contrast; ultrasound, either endoscopic or transabdominal; and MRI (with gadolinium) are potential modes for imaging pancreatic necrosis or abscess. MRI is becoming the imaging study of choice due to concerns regarding the use of iodinated contrast, which is said, by some, to devitalize marginal tissue, increasing the burden of necrotic tissue.
  • The current criterion standard for initial evaluation is contrast-enhanced CT scan, which may reveal ischemic pancreatic tissue as evidenced by the lack of uptake of contrast. There is some suggestion that early CT scan may be detrimental in ANP, with IV contrast worsening ischemia.
  • Consider repeat imaging in all patients with ANP who develop worsening abdominal pain, develop signs or symptoms of obstruction, or have a prolonged clinical course.
  • MRI may be of some additional benefit in the acute evaluation of ANP; gadolinium does not cause a worsening of ischemia in experimental models.
  • Pancreatic necrosis appears as devitalized tissue with decreased IV contrast present on CT scan or MRI. A pancreatic pseudocyst has a rim of fibrous tissue surrounding a pocket of peripancreatic fluid.
    • Earlier accumulations of fluid without the fibrous tissue are referred to as peripancreatic fluid collections, and this formerly was referred to as phlegmon.
    • Demonstrable necrotic tissue in the pseudocyst may exist. Typically, this develops more than 3 weeks after the initial bout of pancreatitis. Contrast-enhanced CT scan of infected pancreatic pContrast-enhanced CT scan of infected pancreatic pseudocyst.
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Procedures

  • Endoscopic drainage
    • EUS-guided transgastric drainage of a pancreatic abscess, with insertion of 2 double-pigtail catheters has also been reported to be useful.[3]
    • Endoscopic necrosectomy and draining may give impressive and immediate symptom relief.[4]
    • No randomized trials have evaluated the minimally invasive techniques for infected pancreatic necrosis, and not all guidelines from professional organizations show "consensus to recommend this minimally invasive management of pancreatic abscess".[5, 6]
    • This lack of agreement likely relates to the fact that successful treatment of symptomatic, sterile or infected walled-off pancreatic necrosis with transoral/transmural endoscopic drainage needs to be followed by percutaneous drainage in 40% or by operative interventions in 20%.[7]
    • Endoscopic drainage of pancreatic fluid collections in persons with acute or chronic pancreatitis is an accepted alternative to surgical intervention, and it provides a successful drainage of the fluid and relief of symptoms in almost 90% of patients.[8] Complications occur in 11%, including death in 5%.
    • In persons with SAP having intervention for infected reasons of infection or abscess, 20% will develop an external pancreatic fistula (EPF).[9]
    • Spontaneous closure of the EPF occurs in 88% of persons in a median of 70 days. Of these 88% whose EPF closes, approximately 24% develop a pancreatic pseudocyst requiring surgical management.
  • CT-guided or ultrasound-guided needle aspiration
    • The presence of either bacterial or fungal flora in pancreatic fluid collections usually aspirated via CT-guided needle biopsy is the sine qua non of pancreatic abscess. The presence of organisms on either Gram stain or culture is essential to establish a diagnosis of abscess.
    • The presence of either bacterial or fungal microbiota in pancreatic fluid collections (usually aspirated via CT-guided needle biopsy) is essential to establish a diagnosis of pancreatic abscess.
    • Pancreatic fluid collections are frequent sequelae of pancreatitis, and endoscopic drainage of these collections is gaining acceptance as an alternative to surgical drainage. Endoscopic ultrasound (EUS)-guided drainage should be reserved for prepancreatic fluid collections located at the pancreatic tail. These fluid collections should be evaluated by EUS before attempts at endoscopic drainage.
    • In the last two decades, the indications for surgery have become less aggressive, focusing more on the treatment of complications such as necrosis, abscess, and pseudocyst.
  • Surgical drainage
    • Even with aggressive intravenous fluid replacement, nutritional support and early intervention of pancreatic necrosis or abscess, the hospital mortality rate of SAP is about 20%.
    • Sterile necrosis may be followed with serial CT-guided drainage and continued antibiotics.
    • Surgical drainage of infected necrosis or an abscess is the procedure for cure. Placement of indwelling drains after the initial procedure may be necessary for complete resolution.
  • Prognosis
    • Risk assessment of acute pancreatitis (AP) depends upon clinical indices (eg, Ranson, Imrie, or Apache I/II Scores), the presence of extrapancreatic complications, an elevated C-reactive protein or hematocrit, an elevated procalcitonin, and the finding of pancreatic necrosis on CT scanning.
    • The prognosis may be worse in obese patients, after trauma, after organ transplantation, after coronary artery bypass surgery, or AP that is idiopathic.[10]
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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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