Emphysematous Pancreatitis in an Immunocompetent Patient

Abstract

Emphysematous pancreatitis (EP) is a quite rare complication of acute pancreatitis (AP) but has a grave prognosis. Gas-forming organisms from the bowel may enter the pancreas to cause EP. Successful treatment requires aggressive management of the infection with early surgical debridement. We report a case of an immuncompetent patient who presented with acute pancreatitis that was complicated with EP. A 65 year-old male with prior cholecystectomy presented with one day of acute diffuse abdominal pain with mild nausea but no vomiting. He reported no new medication, no alcohol use or recent illness. Exam showed diffusely distended tender abdomen with no rebound. His serum lipase and amylase were 29, 3000 and 4735 U/L in order with normal serum triglycerides. CT abdomen showed diffuse peripancreatic inflammatory stranding and fluid consistent with AP (image 1). Diagnosis of AP of unknown cause was made. The patient was treated with bowel rest, IV fluids, and pain medications. He did not improve clinically and was intubated 4 days after due to altered mental status and respiratory distress. One week after, he was found to have worsening abdominal distention, hypotension, tachycardia, oliguria and rising lactate; picture of septic shock although pancreatic enzymes remained low. Urgent CT abdomen showed severe emphysematous pancreatitis complicated by pneumatosis, portal venous gas and free intraperitoneal air in addition to a large extrapancreatic collection containing air and fluid (image 2). He underwent emergent exploratory laparotomy, pancreatic necrosectomy and GJ tube placement. E coli and numerous Bacteroides fragilis were isolated from the necrotic tissue. He was discharged 5 weeks after surgery. EP is a very rare, potentially fatal variant or complication of severe acute pancreatitis with gas in the pancreatic bed. Mortality and morbidity rates approach about 40% and 100%, respectively. There are isolated case reports describing this condition. EP iscaused by necrotizing infection of the pancreas with gas-forming bacteria as E coli, C perfrigens, Staphylococcus, Streptococcus, Klebsiella and Pseudomonas species. The diagnosis is made clinically and and radiologically. Retroperitoneal gas in a patient who has clinical evidence of pancreatitis warrants early use of antibiotics, percutaneous drainage of the fluid collection, and surgical resection of the infected necrotic tissue if there is no clinical response to those measures.Figure 1Figure 2