VA Report: Pancreatic Necrosis & Other Complications of Acute Pancreatitis

Pearl: Infected pancreatic necrosis should be suspected in patients with necrosis or peripancreatic necrosis who deteriorate or fail to improve within 7-10 days of hospitalization.  The guidelines on management of acute pancreatitis from the American College of Gastroenterology are a great (and comprehensive) review.

Pancreatic Necrosis and Infection

  1. In patients with acute pancreatitis, advanced imaging (CT A/P w/ contrast or MRI) should be performed in cases of severe pancreatitis, sepsis, or clinical deterioration 72 hours after initial presentation to look for necrosis or other local complications
  2. For patients with acute necrotizing pancreatitis, infectious complications are a major cause of morbidity and mortality.
  1. Infected necrosis should be suspected in patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7-10 days of hospitalization.
  1. Patients with infected necrosis and sterile necrosis can be clinically indistinguishable (leukocytosis, fever, organ failure) and require needle aspiration to make dx. However, it is controversial whether or not all patients requiring needle aspiration (the alternative is to treat empirically – see algorithm here).
  1. Antibiotics are indicated only if there is infected necrosis (not if it’s sterile)
  1. Definitive management of infected necrosis depends on clinical stability.
    1. In stable patients with infected necrosis, intervention (surgical/radiologic/endoscopic) should be delayed >4 weeks to allow area of necrosis to wall off.
    2. If patients are symptomatic/unstable, earlier debridement is necessary – minimally invasive methods are preferred to open necrosectomy

Local Complications of Acute Pancreatitis
Acute peripancreatic fluid collection
– usually develop within the early phase of pancreatitis
– usually remain asymptomatic, resolve within 7-10 days

Pancreatic pseudocyst
– encapsulated fluid collection with well-defined wall, usually outside the pancreas
– minimal/no necrosis
– usually occur >4 weeks after acute episode

Pancreatic/peripancreatic necrosis (infected or sterile)
– necrotizing pancreatitis often involves both pancreas and peripancreatic tissues

Walled off necrosis (infected or sterile)
– mature, encapsulated collection of necrosis that has well-defined wall
– regardless of whether it has a wall, areas of pancreatic and/or peripancreatic necrosis are initially sterile but may become infected

Click HERE for an Evernote Link!

Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatits. Am J Gastroenterol2013;108:1400-1415.

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