• Pancreatic necrosis develops in about ¹/₅ of acute pancreatitis patients and is usually confirmed through CT scanning
• 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 witho CT FNA, empiric antibiotics should be given
  • Patients with necrosis involving >30% of the pancreas may also need to undergo FNA
•  FNA-confirmed infection may be treated with a step-up approach that includes antibiotics, image-guided drainage, then surgical intervention 
• Antibiotics should be chosen based on culture and sensitivity results and should penetrate well into the pancreas
• Patients who develop infection and have previously received prophylactic 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

• Pancreatic infection calls for prompt debridement or necrosectomy
  
  • Minimally invasive methods of necrosectomy 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