Extensive Pancreatic Necrosis Research Articles

Recurrent Acute Pancreatitis in situs Ambiguous: First Reported Case

Purpose: Heterotaxy is a rare congenital anomaly that describes abnormal symmetry of the thoracic and abdominal organs and vasculature. Heterotaxy includes anomalies such as situs inversus and situs ambiguous. We report a rare case of recurrent acute pancreatitis in which the clinical picture is complicated by underlying situs ambiguous. Case Report: A 67-year-old woman was admitted with acute abdominal pain and vomiting. Clinical presentation, laboratory values and imaging with CAT scan revealed acute pancreatitis as well as incidental situs ambiguous, polysplenia, and intestinal malrotation. Abdominal ultrasound did not demonstrate any evidence of cholecystitis or cholelithiasis. Further diagnostic workup revealed normal serum triglyceride levels, ANA, and IgG4 levels. All medications were reviewed and medication-induced pancreatitis was ruled out. Patient was treated with intravenous fluids and electrolyte supplementation and discharged home. She presented back one month later with the recurrent abdominal pain. At this time, a CAT scan of the abdomen and pelvis revealed worsening pancreatitis with extensive pararenal phlegmon and pancreatic necrosis. MRCP did not reveal any intrahepatic or extrahepatic biliary ductal dilatation, and no pancreatic ductal abnormalities were noted. Patient was managed conservatively with intravenous fluids and electrolyte supplementation and recovered uneventfully. Conclusion: Recurrent acute pancreatitis has not been reported in the literature in a patient with situs ambiguous. We present a rare case of an adult patient with situs ambiguous, polysplenia, and pancreatitis without any duodenal or biliary malformations directly contributory to her pancreatitis. Our case describes a common clinical problem presenting in the setting of a rare anatomical anomaly. Any patient with heterotaxy/polysplenia syndrome with pancreatitis should be aggressively investigated for structural and biochemical abnormalities that could potentially contribute to pancreatitis.Figure: No Caption available.

Necrotizing Pancreatitis Associated With Severe Preeclampsia

Necrotizing pancreatitis is rare in pregnancy and usually is associated with symptomatic cholelithiasis. We present a case of fatal necrotizing pancreatitis in a patient with severe preeclampsia. A 25-year old primigravid woman at 35 weeks of gestation presented with decreased fetal movement, pruritus, and malaise. Intrauterine fetal demise was diagnosed in the context of severe thrombocytopenia, hypertension, proteinuria, hemolysis, elevated transaminases, and renal failure. Postpartum, the patient developed metabolic acidosis, hyperglycemia, and hypoxemia followed by cardiopulmonary arrest and death. Autopsy revealed extensive acute pancreatic necrosis, pleural effusions, ascites, and fatty liver without evidence of microthrombi. The cause of death was acute necrotizing pancreatitis resulting from severe preeclampsia. Severe preeclampsia may cause widespread end-organ damage and may affect the gastrointestinal system, resulting in fatal necrotizing pancreatitis.

STEP-UP COMBINED SURGICAL TACTICS IN THE TREATMENT FOR SEVERE ACUTE PANCREATITIS

Acute pancreatitis remains a major concern of urgent surgery. The aim of the research was to study the results of the use of step-up combined surgical treatment of patients with severe acute pancreatitis. The aim of the research was to study the results of the surgical treatment of 72 patients with severe extensive unlimited pancreatic necrosis. The surgical treatment for severe acute pancreatitis may consist of several steps. The first step is the drainage of the sterile or infected nidi of pancreatic necrosis under ultrasound guidance. The second step includes laparotomy and/or lumbotomy with stepped necrosectomy and debridement (in case of an ineffective first step). The combination of the minimally invasive treatment with «open» surgery can improve the treatment outcomes in the patients with unlimited forms of severe acute pancreatitis.

Acute Pancreatitis

This issue provides a clinical overview of acute pancreatitis focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

When Should We Be Concerned about Pancreatic Necrosis? Analysis from a Single Institution in Mexico City

Although pancreatic necrosis classifies acute pancreatitis (AP) as severe, many patients with tomographic evidence of necrosis never develop systemic complications. Our aim was to analyze the incidence of pancreatic necrosis, organ failure (OF), and the relationship between them. Medical records from 165 patients with a first AP episode and in whom a contrast-enhanced computed tomography (CECT) was performed were analyzed. Pancreatic necrosis was diagnosed as non-enhancing areas of the pancreas on the CECT and was graded as <30%, 30%-50%, and >50%. Pancreatic infection was assessed by guided percutaneous aspiration. Organ failure was defined according to the Atlanta criteria. Of 165 patients (mean age 42 years, 85 men), 54 (33%) had pancreatic necrosis. Necrosis was graded as <30% in 25 subjects (46%), 30%-50% in 16 (30%), and >50% in 13 (24%). Pancreatic infection was diagnosed in 14 cases (26%). Organ failure occurred in 49 patients: in 20 patients (37%) with necrosis, and in 29 patients (26%) without necrosis (P = 0.20). Extensive pancreatic necrosis (>50%) (P < 0.05) and infected necrosis (P < 0.05) were significantly associated with OF. Eight patients, all of them with OF, died. In 6 of these cases infected pancreatic necrosis was present. Patients with pancreatic necrosis are not necessarily at risk of developing OF. However, it should be considered an important risk factor when the necrotizing process compromises more than 50% of the gland and is infected.

Retroperitonealabszess bei schwerer nekrotisierender Pankreatitis

A 65-year-old man was admitted to the emergency unit of another hospital with severe acute abdominal pain. Medial laparotomy revealed a tear in the lower pole of the capsule of the enlarged spleen. Results of some laboratory tests became available only after the procedure: Lipase and amylase levels were markedly elevated at 5097 U/l (normal range < 100 U/l) and 1776 U/l (normal range < 60 U/l), respectively. These findings suggested acute pancreatitis as cause of the acute abdominal pain. Conservative treatment was initiated, but because of progressive clinical deterioration with fever, dyspnea and tachyarrhythmia he was transferred to our hospital for further treatment. Chest X-ray revealed bilateral pleural effusion. Contrast-enhanced abdominal CT scan revealed an acute peripancreatic fluid collection and extensive pancreatic necrosis extending into the perirenal space, hilum of the spleen and transverse mesocolon. Despite the placement of multiple percutaneous pigtail catheters clinical improvement of the severe necrotizing pancreatitis was only temporary and repeated episodes of fever and septicaemia occured. Supported by a multidisciplinary consensus an endoscopic ultrasound (EUS)-guided transgastric drainage of the pancreatic abscess was performed with placement of two double-pigtail catheters and a nasocystic drain for irrigation. After this intervention the patient}s condition rapidly improved, inflammatory parameters normalized and the retroperitoneal abscess gradually resolved. A multidisciplinary consensus and modern interventional approaches such as EUS-guided endoscopic therapy are mandatory to successfully approach severe necrotizing pancreatitis and its complications.

Combined sinus tract endoscopy and endoscopic retrograde cholangiopancreatography in management of pancreatic necrosis and abscess

We report our experience of sinus tract endoscopy (STE) and endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic necrosis and abscess. Thirteen patients with extensive pancreatic necrosis were firstly managed with either percutaneous drainage (PD group; n = 9) or open necrosectomy (ON group; n = 4). Debridement of necrotic tissue was subsequently performed via the drain tract by STE. ERCP was performed only when there was a suspicious of persistent pancreatic duct disruption or choledocholithiasis. In the PD group, the median number of STE sessions required was 3 (range 2-8). The median hospital and ICU stay were 84 days (range 29-163 days) and 0 day (range 0-64 days), respectively, with an overall success rate of 67%. In the ON group, the median number of STE sessions required was 6.5 (range 1-18). The median hospital and ICU stay were 82 days (range 58-194 days) and 19 days (range 4-24 days), respectively. No mortality or failure was noted in the latter group. ERCP was required in nine of 13 patients. Combined ERCP and STE is a useful adjunct in treating pancreatic necrosis or abscess.

A fatal case of pure ethanol ingestion

An adult male was found dead in a car with two empty bottles (500 ml × 2) labeled dehydrated ethanol (>99.5%, v/v). At autopsy, extensive pancreatic necrosis with severe hemorrhage was observed. High concentrations of ethanol were detected in blood (8.14 mg/ml), urine (8.12 mg/ml) and tissue specimens. The cause of death was determined to be an acute alcohol intoxication caused by ingesting approximately 1 l dehydrated ethanol.

Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy.

The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis. Sixty-four patients who underwent pancreatic necrosectomy between 1996 and 2002 were studied. The median age was 60.5 (95 per cent confidence interval (c.i.) 57 to 64) years and 40 patients (62.5 per cent) were tertiary referrals. The initial median Acute Physiology And Chronic Health Evaluation (APACHE) II score was 9 (95 per cent c.i. 7.9 to 10.1) and there were 21 deaths (32.8 per cent). Twenty-eight patients (43.8 per cent) underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and the remainder had open pancreatic necrosectomy (OPN); 44 (72.1 per cent) of 61 patients had infected pancreatic necrosis at the time of the first procedure. Seven patients who underwent MIRP died compared with 14 after OPN (P = 0.240). Patients who died were older than those who survived, with higher APACHE II scores at presentation, and before and after surgery (P = 0.001). Survivors had significantly longer times to surgery than those who died (P = 0.038). All 21 patients who died required intensive care compared with 26 of 43 survivors (P < 0.001). Thirty of 36 patients who had the OPN procedure required intensive care compared with only 17 of 28 patients who had MIRP (P = 0.042). Logistic regression analysis showed that only postoperative APACHE II score was an independent predictor of increased mortality (P = 0.031). Advanced age and increasing APACHE II score, and a need for postoperative intensive care, were the most important predictors of outcome after pancreatic necrosectomy.

ERCP-Induced Acute Necrotizing Pancreatitis

Acute necrotizing pancreatitis (ANP) is an uncommon but serious complication of endoscopic retrograde cholangiopancreatography (ERCP). This study compares the severity, clinical course, and long-term outcome of ERCP-induced ANP with ANP induced by other causes. A review of 72 consecutive patients with ANP treated surgically at the Mayo Clinic identified ERCP as the cause in 6 patients (8%). Compared to the remaining 66 patients, the post-ERCP group had higher APACHE II scores on admission (mean, 13 vs. 10) and more extensive pancreatic necrosis (mean, 55 vs. 47%). The post-ERCP group had a higher rate of infected necrosis (100 vs. 75%) and required earlier necrosectomy after the onset of pancreatitis (9 vs. 13 days). The rate of postoperative pancreatic and enteric fistulae was also higher (50 vs. 33%). Although the mortality rate in the post-ERCP group was lower (17 vs. 29%), they were significantly younger (50 vs. 62 years; p = 0.02) and all the survivors had residual long-term morbidity. ANP is more severe when ERCP-induced; infection introduced during the ERCP may, in part, account for this severity.

Surgical pancreatic complications induced by l-asparaginase

Pancreatitis has been noted to be a potential complication in 2% to 16% of patients undergoing treatment with l-asparaginase for a variety of pediatric neoplasms, but rarely has surgical intervention been necessary. The authors present two fulminant cases of l-asparaginase-induced pancreatitis and review the current literature. The first patient is a 15-year-old boy who underwent induction chemotherapy with l-asparaginase for non-Hodgkin's lymphoma with bone marrow involvement. He presented with diffuse patchy necrosis of the pancreas as well as a large infected pancreatic pseudocyst. He subsequently required operative debridement of the pancreas and external drainage of the pseudocyst. He is currently doing well. The second patient is a 5-year-old boy who was treated with l-asparaginase for a diagnosis of acute lymphocytic leukemia. Within 3 weeks of initiation of therapy, fulminant pancreatitis developed, which progressed to multisystem organ failure. Computed tomography scan demonstrated extensive pancreatic necrosis involving 90% of the gland. He underwent surgical debridement of his necrotic pancreas and wide drainage of the lesser sac. Postoperatively he improved but subsequently multiple complications developed including erosion of his gastroduodenal artery with significant intraabdominal bleeding, which was controlled with angiographic embolization. Subsequently erosion of his endotracheal tube into the innominate vein developed, and he died. l-asparaginase-induced pancreatitis has been described after therapy for various pediatric neoplasms, and the reported cases have usually been self-limiting. However, our cases demonstrate potentially fatal sequelae of this complication and mandate early diagnosis with appropriate surgical intervention in this setting.

Endoscopic therapy for organized pancreatic necrosis

BACKGROUND & AIMS: The treatment of patients with extensive pancreatic necrosis remains controversial; a subpopulation of patients with extensive acute pancreatic necrosis develop complex, organized collections. This study examined the feasibility of endoscopic drainage in patients with extensive organized pancreatic necrosis. METHODS: Eleven patients with organized pancreatic necrosis (8 sterile and 3 infected) after severe acute necrotizing pancreatitis underwent attempted endoscopic drainage. Dynamic contrast-enhanced computerized tomography showed > or = 50% pancreatic necrosis in 10 of 11 patients in whom endoscopic drainage was performed. In 8 patients, an intrapancreatic nasobiliary lavage catheter was placed into the collection concurrently with 10F stents. RESULTS: Complete resolution was achieved nonoperatively in 9 patients. At a mean follow-up of 12 months, 1 patient developed a pseudocyst, which was successfully drained endoscopically. Complications occurred in 5, including bleeding that precluded entry into one collection. CONCLUSIONS: Endoscopic therapy may be a viable management option for a subset of patients who remain symptomatic after an episode of acute pancreatic necrosis after the necrosis has become organized and partially liquefied. Intrapancreatic lavage catheter placement is essential to the success of this procedure. Further evaluation of this technique is needed before this method can be adopted into clinical practice. (Gastroenterology 1996 Sep;111(3):755-64)

Pathology of epizootic haematopoietic necrosis virus (EHNV) infection in rainbow trout ( Oncorhynchus mykiss Walbaum) and redfin perch ( Perca fluviatilis L)

The gross and histopathological lesions of epizootic haematopoietic necrosis virus (EHNV) infection in rainbow trout (Oncorhynchus mykiss Walbaum) and redfin perch (Perca fluviatilis L) were examined during epidemiological studies on an endemically infected trout farm and in experimentally infected fish of the same two species maintained in the laboratory. Intercurrent infections were common in rainbow trout in field outbreaks, producing a variety of lesions and clinical signs, but the following changes were considered due to infection with EHNV in rainbow trout, based on experimental infections. Clinically, moribund fish were dark in colour, inappetent and sometimes ataxic. Gross lesions included abdominal distension, swelling of the spleen and kidney, and, rarely, pale foci in the liver. Microscopical lesions included focal to extensive, acute renal haematopoietic necrosis; multiple tiny foci of acute hepatocellular necrosis; focal to extensive, acute splenic necrosis; mild branchial hyperplasia with occasional focal necrosis; congestion, oedema and necrosis in the wall of the swim bladder; and focal acute necrotizing myocarditis, necrotic cells and debris being prominent within the cardiac lumen (and within blood vessels throughout the body generally). Round to oval basophilic intracytoplasmic inclusions were commonly present in hepatocytes surrounding necrotic foci and were sometimes seen in cells in the interstitium of the kidney, or in the spleen. Less common lesions included focal necrosis of the pancreas, thyroid, pseudobranch, thymus and gastrointestinal crypt epithelium. Intercurrent infections were not observed in redfin perch; gross lesions included multiple pale foci in the liver, haemorrhages at the bases of the fins, swelling of the spleen and kidney, and focal haemorrhages in the gills. Microscopical lesions in haematopoietic kidney, liver, spleen and heart were similar to those in rainbow trout, but the livers had larger focal to locally extensive areas of necrosis. Thrombosis, haemorrhage and fibrinous exudate were common in the gills, and focal to extensive pancreatic necrosis was frequently found. Focal necrosis of the lamina propria of the intestine was also seen. Immunoperoxidase staining in both species revealed EHNV antigen associated with areas of necrosis and in inclusions.

Atheromatous Embolization Resulting in Acute Pancreatitis After Cardiac Catheterization and Angiographic Studies

Acute pancreatitis has a spectrum from mild disease to severe organ destruction resulting in multiple system organ failure. In this study, we report data from 21,680 discharge summaries during a 10-year period of patients who had undergone transabdominal angiographic procedures in whom the diagnosis of pancreatitis was noted in the discharge coding. We detected 39 patients in whom pancreatitis was coded during the same hospitalization, but only nine patients had no other risk factors for pancreatitis other than the temporal relation with the angiographic procedure. Three of these nine patients died of complications caused by pancreatitis. All of the patients with poor outcomes in this report fulfilled more than three Ranson criteria within 48 hours of the original angiographic procedure. Abdominal imaging with ultrasound or computed tomography was abnormal in all the patients who fulfilled more than three Ranson criteria. The histology from the surgical procedures or the autopsies performed on the three patients who died showed extensive cholesterol embolization primarily to the visceral organs. Extensive pancreatic necrosis was evident in these patients. We conclude that acute pancreatitis after transabdominal angiographic procedures is a rare but a potential fatal event. The prognosis from this event is partially predicted by the Ranson criteria that are evident within the first 48 hours.

A Fifteen-Year Experience with Open Drainage for Infected Pancreatic Necrosis

Advances in the understanding of the pathophysiologic factors of acute pancreatitis, combined with several recent technologic breakthroughs, have led to the establishment of infected pancreatic necrosis as the most common, the most severe and the most lethal of the infectious complications of acute pancreatitis. In this report, a single institutional experience in the surgical management of infected pancreatic necrosis during a 15 year period is chronicled. Using open drainage with scheduled abdominal re-explorations, the overall mortality rate was 15 percent in 71 consecutive patients with infected pancreatic necrosis. In the most recent 25 instances, sequential re-explorations were performed until retroperitoneal granulation occurred, at which time the abdomen was closed over lesser sac lavage catheters. Compared with the original 46 patients permitted to heal entirely by secondary intention, patients undergoing delayed secondary closure and lavage had a significant decrease during the hospitalization period (48.8 versus 30.1 days; p < 0.05), without a significant change in the mortality rate. In the most recent patients, dynamic pancreatography and fine needle aspiration bacteriologic factors were accurate in the preoperative prediction of pancreatic necrosis and microbial infection in 95 and 97 percent of the patients, respectively. Preoperative endoscopic retrograde cholangiopancreatography demonstrated leakage of contrast material from necrotic pancreatic ducts in seven of eight patients, while postoperative pancreatograms revealed abrupt truncation or other abnormalities in 11 of 13 patients. These observations establish that necrotizing pancreatitis involves pancreatic parenchyma as well as peripancreatic adipose tissue. Open drainage with contingent secondary closure and high volume lavage deserves a place in the management of patients with extensive infected pancreatic necrosis.

Pancreatitis as a Medical Emergency

Pancreatitis in its acute form, whether from alcohol or gallstones, can be a severe, devastating illness. Patients presumed to have the disease require aggressive fluid therapy and imaging of the pancreas by ultrasound and computed tomography (CT). They should be managed in an intensive care setting until the course of the illness is determined. Surgical intervention is reserved for cases in which extensive pancreatic necrosis or infection is demonstrated by CT scan.

On the Lysolecithin Content of the Pancreas in Experimental Acute Pancreatitis

All the major phospholipid classes were found in the pancreas, pancreaticoduodenal lymph, and arterial blood plasma of anesthetized dogs. The proportion of lysolecithin was significantly higher in the pancreaticoduodenal lymph than in the pancreas; however, its concentration was higher in the pancreas than in the lymph. Retrograde injection of 3% sodium taurocholate failed to increase either the concentration or the proportion of lysolecithin in the dog pancreatic tissue, arterial blood plasma, pancreaticoduodenal venous plasma, or pancreaticoduodenal lymph 30 or 90 min after injection, although at 90 min extensive pancreatic necrosis and highly elevated lipase activity were found in pancreaticoduodenal venous plasma. A mixture of activated pancreatic juice containing lysolecithin increased both the concentration and the proportion of lysolecithin in the dog pancreas and produced focal pancreatic necrosis in 90 min. In the rat pancreas, the retrograde injection of 10 mg of trypsin failed to increase the concentration of lysolecithin 90 min after injection, although it produced acute hemorrhagic pancreatitis. These results cast considerable doubt on the validity of the assumption that lysolecithin formed during the enzymatic hydrolysis of lecithin is responsible for pancreatic injury during the early phases of acute experimental pancreatitis which is induced by either bile salt or trypsin.

A New Geographic and Host Record for Infectious Pancreatic Necrosis

Abstract The occurrence of infectious pancreatic necrosis in rainbow trout (Salmo gairdneri), brook trout (Salvelinus fontinalis), and cutthroat trout (Salmo clarki) has been experimentally authenticated for the first time in the western United States. The cutthroat trout represents a new host. Brook trout fin tissue culture inoculated with bacteria-free filtrate from the diseased fish tissue showed marked degenerative changes after 24 hours. Chinook salmon (Oncorhynchus tshawytscha), kokanee (O. nerka), and silver salmon (O. kisutch) were not susceptible to the virus when inoculated. Histologically, extensive pancreatic necrosis was observed in the original and experimental materials, but striated muscle hyalinization was detected only in the original material.

Parathyropituitary Syndrome in Pituitary Eosinophilism1

THE SIMULTANEOUS occurrence of pituitary disorders and irregularities in calcium metabolism resulting from hyperparathyroidism is frequent enough to warrant close scrutiny and analysis. In an earlier paper (1), abnormal parathyropituitary symptomcomplexes were visualized in two categories: 1. A) Hyperparathyroidism coincidental with eosinophilic hyperpituitarism; and 2. B) Hyperparathyroidism in hyperpituitarism of the basophil variety.3 Consideration of the first category will be undertaken here. THE PARATHYROPITUITARY SYNDROME AS IT MAY APPEAR IN ACROMEGALY Erdheim, 1903 (2), reported a case of acromegaly in a 42-year-old male whose pituitary body was greatly enlarged and presented a microscopic picture of adenomatous growth. In addition to the pituitary adenoma, the same case presented eccentric hypertrophy of the left ventricle with aortic valvular insufficiency, stasis of the organs, plus a form of polyglandular syndrome which included a struma colloides diffusa, an extensive pancreatic necrosis, and...