Emphysematous Pancreatitis Research Articles

Conservative Treatment of Emphysematous Pancreatitis: A Case Report

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

Acute Emphysematous Pancreatitis with Fulminant Multi-organ Failure

급성 ê¸°ì¢ ì„± 췌장염은 ê·¸ 발생 빈도는 매우 드물지만 ìƒëª ì„ ìœ„í˜‘í• ìˆ˜ 있는 급성 췌장염의 심각한 형태이다. ê¸°ì¢ ì„± 췌장염은 장내 가스 형성 ì„¸ê· ì´ 췌장에 침윤하여 발생하는 것으로 ì•Œë ¤ì ¸ 있으며, 복부 ì „ì‚°í™”ë‹¨ì¸µì´¬ì˜ì—ì„œ 췌장 실질 내혹은 후복막강내 ê¸°ì¢ ì´ 형성되어 있는 íŠ¹ì§•ì ì¸ 영상 소견을 보인다. ê¸°ë³¸ì ì¸ 치료는 ì ì ˆí•œ 수액 공급과 ì ì ˆí•œ í•­ìƒì œì˜ 투약으로 감염을 ì¡°ì ˆí•˜ë©°, 임상 상황에 따라 ìˆ˜ìˆ ì  ì œê±° 또는 경피 ë°°ì•¡ìˆ ì„ ê³ ë ¤í• ìˆ˜ 있다. 본 증례는 73세 남성 환자에서 발생한 급성 ê¸°ì¢ ì„± 췌장염이 ì ê·¹ì ì¸ 수액 및 í•­ìƒì œ 치료에도 불구하여 ì „ê²©ì„± 다발성 ìž¥ê¸°ë¶€ì „ìœ¼ë¡œ 진행하여 사망한 1예로 ë¬¸í—Œê³ ì°°ê³¼ 함께 ë³´ê³ í•œë‹¤. Keywords: 급성 괴사성 췌장염, 다발성 ìž¥ê¸°ë¶€ì „, 후복강

Emphysematous pancreatitis with profound shock: A case report

Emphysematous pancreatitis is a rare variant of necrotizing pancreatitis and can be detected easily on computed tomography (CT). In stable patients, surgical intervention is likely to be delayed until conservative management has been attempted and has failed. Rapidly deteriorating manifestations and gas bubbles in and around the pancreas on CT are findings suggestive of infected pancreatic necrosis, and early necrosectomy may be indicated in such cases. We herein report the case of a 61-year-old woman with a history of diabetes mellitus and gallstones who presented with general soreness, vomiting, decreased urination, and abdominal fullness for three days. The findings on CT suggested a diagnosis of emphysematous pancreatitis. Hence, vigorous fluid resuscitation and intravenous meropenem administration were started immediately. The patient received a laparotomy and focal necrosectomy with closed lesser sac lavage and drainage on the next day. She recovered successfully and was discharged after one month. The early presence of gas in and around the pancreas on CT possibly implies secondary infection, and in such cases, surgical intervention should be considered.

A Diagnosis That’s Up in the Air

Question: A 61-year-old man presented with severe upper abdominal pain. He had a history of moderate alcohol intake, but no prior pancreatic disease. On physical examination he was afebrile with upper abdominal tenderness and voluntary guarding. Laboratory studies were notable for: aspartate aminotransferase, 118 U/L (normal, <48); alanine aminotransferase, 114 U/L (normal, <55); creatinine 3.8 mg/dL (normal, <1.3); and lipase, 3,843 U/L (normal, <73). A computed tomographic (CT) scan of the abdomen without contrast was obtained (Figure A). Urgent endoscopic retrograde cholangiopancreatography was performed and biliary sludge and 1 stone were removed. He developed progressive multiorgan failure over the next week, including septic shock requiring vasopressor support, acute renal failure requiring dialysis, and hypoxemic respiratory failure necessitating mechanical ventilation. Subsequently, a CT-guided fine-needle aspiration of a peripancreatic fluid collection revealed polymicrobial growth of Escherichia coli, Klebsiella pneumoniae, Enterococcus casseliflavus, and Candida albicans. What is the diagnosis? Look on page 1429 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The CT image obtained at initial presentation demonstrates air within the pancreatic parenchyma and an acute peripancreatic fluid collection abutting the tail of the pancreas. A large gallstone was also noted. Emphysematous pancreatitis is a rare variant of severe acute pancreatitis. The phrase has been used ambiguously for many years, but in the purest form describes air located within the pancreatic parenchyma. This is analogous to other entities such as emphysematous cholecystitis and gastritis. Semantically, this is distinguished from infected walled off pancreatic necrosis, in which air is seen within a defined collection.1Banks P.A. Bollen T.L. Dervenis C. et al.Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus.Gut. 2013; 62: 102-111Crossref PubMed Scopus (3608) Google Scholar The origin of the air seen within the pancreatic parenchyma at the onset of pancreatitis is not understood. In well-formed collections, microbial isolation of a gas-forming organism is uncommon, leading some authors to believe such air is the consequence of a fistulous communication to the gastrointestinal lumen (stomach, duodenum, or colon). Because the terminology of emphysematous pancreatitis is used loosely, existing series generally do not discriminate between those with air in the parenchyma or within a defined pancreatic fluid collection. It may be the case that these 2 entities represent the same disease process at different points in time; however, we believe that patients with intraparenchymal air have a worse outcome. Historically, intraparenchymal air was an indication for surgical debridement. However, there are emerging data, including the current report, in which patients can be successfully managed nonsurgically with a combination of antibiotics, percutaneous drainage, and/or endoscopic treatment.2Kvinlaug K. Kriegler S. Moser M. Emphysematous pancreatitis: a less aggressive form of infected pancreatic necrosis?.Pancreas. 2009; 38: 667-671Crossref PubMed Scopus (19) Google Scholar, 3Nadkarni N. D'Cruz S. Kaur R. et al.Successful outcome with conservative management of emphysematous pancreatitis.Indian J Gastroenterol. 2013; 32: 242-245Crossref PubMed Scopus (11) Google Scholar Despite the use of broad-spectrum antibiotics and maximal medical support, this patient progressively deteriorated clinically. He underwent direct endoscopic necrosectomy on hospital days 14 and 16 (approximately 3 weeks after onset of symptoms). A temporary percutaneous drain was placed into a left paracolic gutter extension. He was discharged 1 month later, and was tolerating an oral diet without the need for supplemental oxygen or dialysis. As an outpatient, 2 additional endoscopic débridements were performed and all stents were removed 3 months after discharge (Figure B). This case illustrates an uncommon variant of pancreatitis in which gas was present in the parenchyma at the time of initial presentation. Previously, emphysematous pancreatitis was felt to be an absolute indication for surgical debridement, but this case, amongst others, illustrates the possibility for successful nonoperative management. Dr Baron is currently affiliated with University of North Carolina Chapel Hill.

Emphysematous pancreatitis predisposed by Olanzapine.

A 32-year-old male presented to our intensive care unit with severe abdominal pain and was diagnosed as acute pancreatitis after 2 months of olanzapine therapy for bipolar disorder. His serum lipase was 900 u/L, serum triglyceride 560 mg/dL, and blood sugar, fasting and postprandial were 230 and 478 mg/dL, respectively on admission. Contrast enhanced computed tomography (CECT) of abdomen was suggestive of acute pancreatitis. Repeat CECT showed gas inside pancreas and collection in peripancreatic area and patient underwent percutaneous drainage and antibiotics irrigation through the drain into pancreas. We describe the rare case of emphysematous pancreatitis due to development of diabetes, hypertriglyceridemia and immunosuppression predisposed by short duration olanzapine therapy.

An Atypical Presentation of Acute Pancreatitis in the Setting of Diabetic Ketoacidosis

Background: Patients with diabetic ketoacidosis (DKA) frequently present with abdominal pain often from metabolic acidosis, but potentially can have co-existing acute pancreatitis (AP), appendicitis, or gastrointestinal perforation. However, it is rare for acute pancreatitis to present as DKA. We report a case in a patient with no past medical history presenting with multiorgan failure and DKA in the setting of severe acute pancreatitis, which progressed into emphysematous pancreatitis. His diabetes resolved with the resolution of severe pancreatitis. Case Report: We report a case of a 37-year-old male with no significant medical history who presented with multiorgan dysfunction syndrome, DKA, and acute pancreatitis. This patient had a prolonged hospital course with initial resolution of his acute pancreatitis; however, was later complicated by fevers, jaundice, and abdominal distension. Imaging revealed pancreatic necrosis. The patient was managed via medical therapy and underwent an ERCP for biliary decompression. Over the course of the year, his pancreatic necrosis and biliary obstruction resolved without surgical intervention. On 1-year follow-up, his diabetes also resolved.FigureFigureConclusion: We postulate that severe pancreatitis could have lead to dysfunction of beta cells, and hence decrease production of insulin, which resulted in DKA and masked coexisting AP. A high index of suspicion for acute pancreatitis should remain in patients with DKA who have severe abdominal pain, as the diagnosis of acute pancreatitis could impact the management of these patients.

Successful outcome with conservative management of emphysematous pancreatitis

Surgery is the mainstay treatment of emphysematous pancreatitis (EP). The aim of the present study was to assess the outcomes of patients with EP managed nonsurgically. The patients with EP without organ dysfunction were managed nonsurgically with antibiotic therapy, nutritional support, and if required radiological drainage. The main outcome measure was survival. Nine patients were diagnosed with EP. They had computed tomographic severity index of 10, APACHE score of 11 (±3.4), and Ranson's score of 4.2 (±1.2) in the first 24-48 h. All had monomicrobial infection of the pancreatic necrosis (Escherichia coli in 4/9, Pseudomonas aeruginosa in 3/9, and Klebsiella pneumoniae in 2/9 patients). All these patients were managed with antibiotics as per sensitivity reports (piperacillin-tazobactum in 5/9, imipenem in 3/9, and ciprofloxacin-metronidazole in 1/9 patients) and nutritional support. Seven of nine patients improved within 1 week of starting antibiotics. Two patients required percutaneous catheter drainage in addition. One of the patients had progressive organ dysfunction and was subjected for surgery. All 8/9 patients who were managed conservatively survived (89 % survival). The only patient who underwent surgery expired (11 % mortality). In EP without organ dysfunction, a trial of conservative management may be successful.

A Case of Acute Emphysematous Pancreatitis

Emphysematous infections of the abdomen are potentially life-threatening conditions that require aggressive medical and surgical management. Emphysematous pancreatitis is an uncommon disease that presents as acute pancreatitis with intra-parenchymal gas at the time of diagnosis. Traditionally, emphysematous pancreatitis is an indication for surgical intervention. However, a few cases of emphysematous pancreatitis, managed successfully without surgical debridement have been reported. We present a case of emphysematous pancreatitis managed medically without surgical debridement in a 56-year-old male. (Korean J Med 2012;83:485-489)

Favorable Outcomes with Conservative Management in Patients with Emphysematous Pancreatitis and Spontaneous Intestinal Fistulization

Purpose: Emphysematous pancreatitis (EP) is characterized by the presence of intraparenchymal pancreatic air in the setting of necrotizing pancreatitis. Traditionally, EP has been an indication for surgical intervention. We encountered three patients with EP, all with spontaneous small bowel fistula, who did well with conservative management alone. Methods: Case series of 3 cases of EP. Results: Case 1. A 37 year old male brought to ER with altered mental status and CT scan showed severe pancreatitis. He was managed with supportive care. After 4 weeks patient developed jaundice and CT scan of abdomen showed hemorrhagic pancreatitis, and he underwent ERCP with stent placement. A repeat ERCP after 6 weeks for stent exchange showed a large fistula near major papilla and CT showed EP. Patient continued to be managed conservatively. Now after 1 year his EP has resolved. Case 2. 49 yr old with PMHx of pancreatitis 4 weeks ago came with epigastric pain and found to have lipase of over 10,000 U/L. CT showed severe pancreatitis with areas of necrosis and emphysematous changes. EUS showed a duodenal fistula. He was treated conservatively without antibiotics. 4 weeks later, repeat CT showed significant improvement in EP. He underwent cholecystectomy and now after 2 years his EP has completely resolved. Case-3: 57-year-old male who came to ER with epigastric distress and found to have an ST elevation myocardial infarction and CT scan of abdomen showed pancreatitis. Repeat CT after 4 weeks showed air in the pancreas, although he was feeling well. After 6 weeks of his CT scan, he had an episode of GI bleeding; an EGD showed a bleeding fistula between the pancreas and duodenum. Follow up CT scan in 1 year from his initial episode of pancreatitis showed complete resolution of EP. Conclusion: Traditionally EP is managed by surgical debridement which has mortality of 25%, and morbidity of 100%. Our case series suggests that patients with EP who are not septic or critically ill may have developed spontaneous fistulas and might be good candidates for conservative management.Figure: Case 1: Patient with emphysematous pancreatitis and spontaneous intestinal fistulization who mas managed conservatively.

Fulminant type of emphysematous pancreatitis has risk of massive hemorrhage.

Emphysematous pancreatitis (air in the parenchyma) was previously considered an indication for surgery, but some recent studies have reported good clinical outcomes with non-operative management. As a step toward establishing a better treatment strategy, we report a case of fulminant pancreatitis with massive hemorrhage into the emphysematous space. A 75-year-old man was admitted with worsening abdominal pain with obstructive jaundice and renal failure 28h after the onset. He was diagnosed as having emphysematous pancreatitis with slight pancreatic necrosis. Despite conservative treatment with intensive care, sudden cardiac and respiratory failure occurred, and he died 53h after onset. The autopsy findings revealed biliary sludge and massive bleeding in the retroperitoneal space around the pancreas, suggesting that temporary obstruction of the bile duct with sludge induced emphysema and the hemorrhage rapidly spread into the broadened emphysematous space. Whereas conservative management has been thought to be appropriate in selected cases of emphysematous pancreatitis, when there is pancreatic emphysema in the early phase, a fulminant course tends to develop. Since there is a risk of massive bleeding into the emphysematous space, endoscopic or invasive drainage performed to collapse the emphysematous space could benefit the outcome.

Exceptional, potentially fatal combination of emphysematous pancreatitis and gas-forming cholecystitis: successful multi - disciplinary conservative treatment supported by repeated ctstaging

Usually considered as a life-threatening disease, emphysematous pancreatitis requires early diagnosis and aggressive multidisciplinary treatment including the Departments of Gastroenterology, Intensive Care Medicine, Interventional Radiology and even Surgery. The prognosis for emphysematous cholecystitis is also quite poor. It requires surgery even if a percutaneous cholecystostomy can contribute to a temporary stabilization of the patient. Computed tomography is the imaging modality of choice to detect emphysematous pancreatitis and gas-forming cholecystitis. It enables their grading and helps identify their complications. Moreover, it proves essential in the follow-up of the lesions.

Simultaneous emphysematous cholecystitis and emphysematous pancreatitis: a case report

Emphysematous infections of the abdomen and pelvis are potentially life-threatening conditions that require aggressive medical and surgical management. Therefore, early radiographic detection of emphysematous infections is important in management. Emphysematous cholecystitis is a rare and severe form of acute cholecystitis caused by gas-forming organisms. Emphysematous pancreatitis is a rare form of pancreatitis with gas in pancreatic parenchyma. We report a rare case of simultaneous occurrence of emphysematous cholecystitis and emphysematous pancreatitis.

Acute Emphysematous Pancreatitis

Acute emphysematous pancreatitis represents a rare and potentially life-threatening infection and is characterized by gas formation within or around the pancreas. We present a case of acute emphysematous pancreatitis managed conservatively.

Pancreatitis enfisematosa. ¿Tratamiento conservador o quirúrgico?

Emphysematous pancreatitis is a severe and rare complication of acute pancreatitis. This entity is diagnosed on clinical grounds and on the basis of the radiologic finding of gas in the retroperitoneum. Infected pancreatic necrosis is potentially lethal, with mortality rates of more than 35%. Surgery is associated with significant morbidity and mortality in these critically ill patients. Endoscopic ultrasonography techniques, laparoscopic surgery and percutaneous drainage have the potential to offer a safe and effective alternative treatment modality. However, the precise role of these procedures requires further investigation. The treatment of these patients should be individualized, dynamic and multidisciplinary. We present two cases of emphysematous pancreatitis with distinct therapeutic management.

Emphysematous Pancreatitis

Emphysematous pancreatitis is characterized by the presence of intraparenchymal pancreatic air in the setting of necrotizing pancreatitis. Mortality and morbidity rates approach approximately 40% and 100%, respectively. Traditionally, emphysematous pancreatitis was an indication for surgical intervention. The purpose of this review was to discuss our experience with nonoperative management of emphysematous pancreatitis. Between July 2005 and August 2007, 5 patients with emphysematous pancreatitis were admitted to Royal University Hospital (Saskatoon, Saskatchewan, Canada). The cases are described in the context of the current literature. The 5 male patients ranged in age from 50 to 77 years. Four required at least 1 week in the intensive care unit. All 5 cases of emphysematous pancreatitis went on to be treated successfully with nonoperative management. Furthermore, after a minimum of 1-year follow-up, they remain out of hospital and continue to do well. Our data suggest that emphysematous pancreatitis may be a favorable subtype of severe pancreatitis. In well-selected patients, nonoperative management with aggressive antibiotic treatment and nutritional support may suffice.

Emphysematous pancreatitis: The utility of CT

Emphysematous pancreatitis is a rare variant of severe acute pancreatitis characterized by gas formation within and around the pancreas. Early radiology detection of retroperitoneal gas in patients with pancreatitis is important in view of the high morbidity and mortality associated with this condition. Computed tomography is the imaging modality of choice. It is both highly sensitive and specific in the detection of abnormal gas and is well-suited to reliably depict the anatomical location and extent of the gas.

Concurrent Emphysematous Cholecystitis and Emphysematous Pancreatitis: A Case Report

Emphysematous infections of the abdomen and pelvis are potentially life-threatening conditions which require aggressive medical and surgical management. Therefore, early radiographic detection is important in the management of these conditions. Concurrent emphysematous infections involving different organs have been rarely reported, and primarily occur in immunocompromised patients. Here, we report a rare case of concurrent emphysematous cholecystitis and emphysematous pancreatitis in a 97 year old male patient.

Medical management of emphysematous pancreatitis

Medical management of emphysematous pancreatitis

Pancreatitis por Clostridium perfringens con retroneumoperitoneo extenso

We present a case of primary emphysematous pancreatitis caused by Clostridium perfringensinfection (also known as spontaneous pancreatic gas gangrene) in a 66-year-old man with diabetes and a history of recurrent pancreatitis.One notable feature is the absence of a focal distribution, which is seen on radiological studies to be accompanied by extensive retropneumoperitoneum, with dissemination of the gas toward the mesenteric root and pelvic extraperitoneal spaces. This wide diffusion is aided by the C. perfringens toxins and the pancreatic enzymes released, leading to a fulminant course, an elevated rate of early mortality among the cases reviewed. The early diagnosis of this disease is fundamental, enabling aggressive medical treatment and emergency surgery.Diabetes is a known risk factor for anaerobic infection, including C. perfringens, as in the case of emphysematous cholecystitis.A diseased pancreas or pancreatic duct facilitates the development of infections since it eliminates poorly the microorganisms that reach it from the duodenum.Gas gangrene secondary to necrosis-related superinfection or pancreatic collections is uncommon, and spontaneous or primary cases are exceptionally rare.