Pancreatitis%20-%20acute Management

• Pancreatic necrosis develops in about 20% of acute pancreatitis patients (typically moderately severe or severe) and is usually confirmed through CT scanning
• Associated with early organ failure, need for intervention, and mortality 
• When patients do not suffer from organ failure or systemic toxicity, pancreatic necrosis may usually be treated conservatively with IV fluids and analgesia
• Infected necrosis of the pancreas should be suspected in patients who exhibit organ dysfunction or systemic toxicity after 7-10 days
  
  • Infected necrosis may be diagnosed either by the presence of gas within the pancreatic collection or by FNA
  • CT-guided FNA of the infected necrosis with Gram stain and culture for aerobic and anaerobic bacteria and for fungi should be done if infected necrosis is being considered and to distinguish it from sterile necrosis 
  • If without CT FNA, empiric antibiotics should be given
• Patients with necrosis involving >30% of the pancreas may also need to undergo FNA
• Patients who develop infection and have previously received antibiotics should be considered as having a healthcare-associated infection

Sterile Necrosis

• Clinically mild and not usually associated with systemic complications
  • Clinically stable patients should be managed non-surgically and antibiotics are not needed
• If organ failure and systemic toxicity improve, medical therapy should be continued and may consist of systemic antibiotics to prevent secondary pancreatic infection
  • These patients occasionally need surgical intervention but this is uncommon

Infected Necrosis

• FNA-confirmed infection may be treated with a step-up approach that includes antibiotics, percutaneous or endoscopic drainage, then surgical intervention
• Antibiotics should be chosen based on culture and sensitivity results and should penetrate well into the pancreas
• Percutaneous drainage may result in resolution of infection in 25-60% of patients
• When percutaneous drainage fails, pancreatic infection calls for prompt debridement or necrosectomy
  
  • Minimally invasive methods are preferred to open methods
• In stable patients, interventions (eg surgical, radiologic and/or endoscopic drainage) should be done after >4 weeks to permit content liquefaction and fibrous wall formation around necrosis

• A follow-up CECT scan may be performed 7-10 days after the initial CT scan in patients with severe acute pancreatitis   
  • Additional CECT scans may be done only if patient’s condition does not improve or if an invasive intervention is being considered  

Patients treated for acute pancreatitis should be followed up for the common complications of the disease and treated accordingly

Pancreatic Pseudocyst

• A pseudocyst contains pancreatic enzymes and tissue debris and is usually sterile
• If asymptomatic, the pseudocyst does not need intervention
• The development of clinical symptoms, eg abdominal pain or fever, or the increasing size on serial imaging should prompt therapeutic intervention 
• Treatment options include surgical, radiologic and endoscopic methods, eg decompression via endoscopic cyst gastrostomy with endoscopic ultrasound guidance

Pancreatic Abscess

• Most abscess occur at least 4 weeks following the onset of acute pancreatitis
• Treatment is through percutaneous or surgical drainage