Fulminant Emphysematous Pancreatitis

Abstract

A 60-year-old chronic alcoholic presents with 1 day of severe epigastric pain and vomiting after drinking copious amounts of alcohol. Examination revealed a guarded abdomen with severe epigastric tenderness. He was afebrile, but had atrial tachyarrhythmia, tachypnea, and hypotension. Laboratory investigations demonstrate elevated amylase and lactate with severe metabolic acidosis. Liver function tests were normal. A computed tomography scan of the abdomen and pelvis showed extensive retroperitoneal gas around the pancreas extending along the duodenum into the subhepatic region (Figure A, blue arrow). The proximal portion of the pancreas appeared largely replaced by gas (Figure B, red arrow). The biliary tree was not dilated. There was no evidence of perforation. A diagnosis of severe acute emphysematous pancreatitis was made, likely from alcoholism. This patient subsequently developed increasing ventilatory and inotropic support and despite being nursed in the intensive care unit, he succumbed within 24 hours. Emphysematous pancreatitis is an unusual, but lethal complication of acute pancreatitis when there is necrotizing infection by gas-forming bacteria, such as anaerobes, and gram-negative bacteria, such as Escherichia coli. Although this is a rare presentation, there have been several additional reports in the literature describing emphysematous pancreatitis. Its prognosis is extremely poor. Timely antibiotic administration and/or percutaneous drainage of the fluid collection is critical. Surgical resection of infected necrotic tissue may be warranted failing supportive measures. The content of this paper has not been published or submitted for publication elsewhere. All authors have contributed significantly and all authors are in agreement with the content of the manuscript. Written consent as obtained from the patient.