Conservative Treatment of Emphysematous Pancreatitis: A Case Report

Abstract

A 55 year old male with a history of diabetes mellitus, cholelithiasis requiring cholecystectomy, appendectomy, and alcohol-induced pancreatitis presented to an outside hospital for abdominal pain, nausea, and vomiting. His initial labs were notable for a lipase of 4000 U/L and acute kidney injury with Cr of 1.6 mg/dL. The patient had a Computed Tomography (CT) of abdomen and pelvis showing acute pancreatitis. After several days, he developed a fever and was placed on Piperacillin-Tazobactam. Blood cultures obtained prior to the initiation of antibiotics grew Klebsiella pneumonaie. Because of continued fevers, a repeat CT scan was done and showed development of a pancreatic abscess. Repeat labs were within normal limits except for an elevated total bilirubin of 2.5 mg/dl and an alkaline phosphatase level of 210 U/L. A third CT scan showed extensive pancreatic inflammation and air consistent with emphysematous pancreatitis with an abscess in the lesser sac measuring 6.6 x 4.7 cm. At this point, his antibiotic was switched to meropenem and he was transferred to our facility. Upon arrival, the patient had a heart rate of 102bpm with otherwise normal vital signs. He was still complaining of abdominal pain, nausea and vomiting and had epigastric tenderness on exam. Abnormal labs included a leukocytosis of 16,500 x 103/μL, alkaline phosphatase of 296 U/L, and an albumin of 2.0 g/dL. Amylase and lipase were both 10 U/L. A CT scan at our facility showed progression of emphysematous pancreatitis with pseudocyst formation along the anterior aspect of the pancreatic tail. Since he remained hemodynamically stable, decision was made to defer intervention on his pancreas until a later date. He was discharged on levofloxacin and metronidazole. The patient did have a brief hospitalization for a flare of acute pancreatitis after discharge but otherwise did well. Two months after his arrival at our hospital, he underwent an upper endoscopic ultrasound showing a 7 cm single compartment, thick walled pancreatic cyst without septae in the pancreas which was endoscopically drained. An endoscopic necrosectomy with removal of residual necrotic debris was also performed. He tolerated the procedure well without any complications. Cultures from both of these procedures grew Candida Glabrata and Klebseilla Pneumoniae and he was discharged on a course of Bactrim, Metronidazole, and Fluconazole. Subsequent CT scans showed complete resolution of the pancreatitc necrosis.Figure 1