|
 
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| CASE REPORT |
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| Year : 2022 | Volume
: 25
| Issue : 3 | Page : 89-92 |
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Management of pancreatic abscess following acute pancreatitis
Nnamdi Jude Nwashilli1, Blessing Ose-Emenin Igbinedion2
1 Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Radiology, University of Benin, Benin City, Edo State, Nigeria
| Date of Submission | 21-Sep-2020 |
| Date of Decision | 16-Jan-2021 |
| Date of Acceptance | 02-Mar-2021 |
| Date of Web Publication | 20-Nov-2023 |
Correspondence Address:
Dr. Nnamdi Jude Nwashilli
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/smj.smj_127_20
Pancreatic abscess occurs as sequelae of acute pancreatitis. The standard treatment of infected pancreatic abscess is open surgical drainage and antibiotics. Recently, minimally invasive drainage methods such as image-guided percutaneous catheter drainage, transluminal endoscopic drainage through the stomach or duodenum, and retroperitoneal surgical drainage are becoming the trend. Open surgical drainage has a drawback of triggering a strong inflammatory response that can lead to multi-organ failure, bleeding, and gastrointestinal fistula unlike the minimally invasive approach. However, in the absence of facilities and expertise for minimally invasive drainage techniques, coupled with a patient with extensive/diffuse pancreatic necrosis and clinical deterioration, open surgical drainage may suffice. We report a case of pancreatic abscess which developed in a middle-aged man after few months of treatment and recovery from acute pancreatitis that was managed by open surgical drainage and parenteral antibiotics with good outcome.
Keywords: Good outcome, open surgical drainage, pancreatic abscess
How to cite this article:
Nwashilli NJ, Igbinedion BO. Management of pancreatic abscess following acute pancreatitis. Sahel Med J 2022;25:89-92 |
| Introduction | |  |
Pancreatic abscess is a late complication of acute necrotizing pancreatitis which occurs 4 weeks after the initial attack. The presence of fluid and necrotic tissues around the pancreas may occur following acute pancreatitis. This can be classified as acute or delayed, depending on whether it is less than or more than 4 weeks, respectively.[1] In the acute period, the fluid is described as peri-pancreatic fluid. After 4 weeks, it becomes organized with a definite wall and it is a pseudocyst. When a pseudocyst becomes infected, it is called a pancreatic abscess. Pancreatic necrosis is an acute necrotic tissue with fluid walled-off by fibrotic and inflammatory wall. It occurs in approximately 15% of patients with acute pancreatitis with attendant morbidity and mortality.[2] Following bacteria invasion, it becomes infected necrosis.
Complications that may occur in pancreatic abscess include abdominal pain, rupture of the abscess leading to peritonitis, fistula formation, erosion into vessels with acute hemorrhage, pancreatic ascites, and pleural effusion. A hollow viscus obstruction can occur from compression of surrounding structures, including transverse colon, stomach, duodenum, and the common bile duct. Some of these complications are debilitating and life-threatening. The mortality rate of sterile pancreatic abscess is 10% and rises to 30% with infection.[3] Infection occurs in pancreatic abscess in one-third of patients.[4] A meta-analysis concluded that in the presence of infected pancreatic abscess and organ failure, mortality approaches 43%.[4]
We report a case of pancreatic abscess which developed after few months of acute pancreatitis that was managed by open surgical drainage with good outcome.
| Case Report | | |
A 55-year-old male presented with mid-upper abdominal pain and fever of 2 weeks duration. There was associated generalized body weakness, dizziness, unproductive cough, and difficulty in breathing. Four months earlier, he had presented with upper abdominal pain, vomiting, fever, and mid-upper abdominal swelling. He was febrile, tachycardic, hypotensive with a palpable epigastric mass. Serum amylase was markedly elevated. He took alcohol occasionally but never smoked cigarette. A diagnosis of acute pancreatitis was made, and he was admitted into the intensive care unit. He was on nothing by mouth, intravenous fluid, analgesics, antipyretics, total parenteral nutrition, and dopaminergic support for 2 weeks. He recovered and was discharged. He was re-admitted 3 months after discharge following mid-upper abdominal pain and fever.
General examination revealed a middle-aged man, chronically ill-looking, febrile (temperature: 38°C), pale, dehydrated, not cyanosed, anicteric, with bilateral pitting pedal edema up to mid-leg and no peripheral lymphadenopathy. His abdomen was full, moved with respiration. There was a firm, tender mass located in the epigastrium, measuring 8 cm × 10 cm, one could get below it, but not above it. The liver and spleen were not palpably enlarged, and the kidneys were not ballotable. There was ascites demonstrable by shifting dullness. Digital rectal examination was normal. Pulse rate was 110 beats/min (normal: 60–100), blood pressure 120/80 mmHg, and heart sounds were 1 and 2 with no murmurs. Respiratory rate was 32 cycles/min (normal: 12–18), breath sound was vesicular with bi-basal coarse crepitations.
His hemoglobin was 6.4 g/dl (normal: 13.5–17.5), serum amylase 201 μL (normal: 25–125), total white blood cell 4.0 × 103/μL (normal: 4.0–10 × 103), and platelet 165 × 103 μ/L (normal: 150–400,000). Serum calcium, phosphate, electrolytes, urea and creatinine, fasting blood sugar, and liver function tests were normal. The total serum protein was 5.3 g/dl (normal: 6.0–8.0), serum albumin 1.5 g/dl (normal: 3.5–5.0), and globulin 3.8 g/dl (normal: 2.5–3.0). Abdominal computed tomography scan (CT scan) revealed pancreatic abscess/necrosis [Figure 1]a and [Figure 1]b. Chest X-ray was normal. | Figure 1: (a) Abdominal computed tomography scan of the patient at presentation showing diffusely enlarged pancreas with surrounding fatty strands. (b) Contrast-enhanced abdominal computed tomography scan showing pancreatic abscess as an area of fluid collection with pockets of gas and peripheral enhancement
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He was transfused with a total of six units of blood and post transfusion hemoglobin appreciated to 11 g/dl. He was on nothing by mouth, intravenous fluids, intravenous Meropenem, Metronidazole and Paracetamol. Laparotomy through an upper midline incision was carried out to drain the pancreatic abscess. Intraoperative findings were: inflammatory mass formed by the greater omentum and transverse colon with adherent jejunal loops and necrotic pancreatic tissue and pus [Figure 2]. Other intra-abdominal organs were normal. Pus and necrotic tissues were evacuated [Figure 3]. The pancreatic bed was lavaged with warm normal saline, and a wound drain was inserted into the lesser sac. Postoperatively, the wound drain effluent tailed off, and it was removed on the 7th day. The purulent fluid/necrotic tissue cultured Escherichia More Details coli that was sensitive to Imipenem which was subsequently administered to the patient and the infection resolved. Hypokalemia was noted on the 4th day postoperative, and it was corrected with intravenous potassium chloride (KCL). He was discharged on the 14th day postoperative period and sutures were removed. He is presently being followed up on out-patient clinic visitations without recurrence. A repeat abdominal CT scan carried out 6 months after discharge revealed resolution of the pancreatic abscess [Figure 4]. | Figure 2: Intra-operative access into the lesser sac via upper mid-line abdominal incision and gastro-colic omentum for drainage and evacuation of pancreatic necrotic tissues and fluid
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 | Figure 4: Abdominal computed tomography scan of the patient after 6 months of hospital discharge showing resolution of the abscess/necrosis
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| Discussion | | |
In pancreatic peri-pancreatic collection, abscess is suggested by fluid collection, peripheral enhancement, and the presence of gas on contrast-enhanced abdominal CT scan. Other factors that may be indicative of infected necrosis include the presence of fever, bacteremia, leucocytosis, feeling of unwell, and clinical deterioration in the background of acute pancreatitis or postresolution of acute pancreatitis. The index case presented with persistent fever and feeling of unwell, few months after being treated for acute pancreatitis. A contrast-enhanced abdominal CT scan revealed the features of pancreatic necrosis with the presence of gas.
Initiation of broad-spectrum parenteral antibiotics with good penetration into the pancreas is recommended in infected pancreatic abscess.[5] These include quinolones, metronidazole, and third or higher generation cephalosporins. Ideally, a CT-guided percutaneous biopsy of necrotic collections for culture would guide in the appropriate selection of antibiotics but was not performed for the index patient as it had been decided to carry out open surgical drainage on emergency to avoid further delay. The surgically evacuated necrotic tissues and fluid sent for culture yielded E. coli sensitive to Imipenem. The patient was treated with Imipenem, 500 mg, eight hourly for 7 days with resolution of the fever.
Although open surgical debridement has been the traditional treatment for pancreatic abscess, it has been suspected that the physiological stress associated with it increases complications.[2] A paradigm shift is now adopted in the treatment of pancreatic abscess and peri-pancreatic infections. Open surgical procedures are being replaced by endoscopic or percutaneous procedures. Open surgery is now reserved for cases in which endoscopic or percutaneous approach is not feasible. A randomized trial on minimally invasive techniques in infected pancreatic abscess favored endoscopic approach over open surgery.[6] The endoscopic route results in lower morbidity rates, recovery, and a shorter hospital stay.
Percutaneous catheter drainage was originally used in draining residual collections after open necrosectomy,[7] but it has been stepped-up to a state that it can defer or obviate the need for open surgery and may serve as adjunct to endoscopic necrosectomy.[8] The drawback of percutaneous catheter drainage is the risk of pancreatico-cutaneous fistula. A combination of percutaneous approach with endoscopic drainage can prevent fistula and avoid repetitive endoscopic interventions in performing necrosectomy.[9] A single center case–control series showed that combined percutaneous-endoscopic approach increases the rate of nonsurgical resolution and result in a decrease in hospitalization, time to drain removal, number of CT scans and number of drains compared to percutaneous drain alone.[9],[10] Darrivere et al. in a single-center observational study reported that minimally invasive drainage like percutaneous drainage and endoscopic necrosectomy had a better outcome compared to open surgery in critically ill patients with infected pancreatic abscess.[11] The index case had open surgery for drainage of the pancreatic fluid and evacuation of necrotic tissues due to nonclinical improvement (emergency nature), departmental protocol, lack of facilities, and equipment to carry out the drainage using minimally invasive technique, although the expertise was available with good outcome.
| Conclusion | | |
Although minimally invasive techniques are gradually becoming the trend in managing infected pancreatic abscess, no single approach appears to be optimal in all patients. Open surgical debridement still has a role in the management of pancreatic abscess even in the midst of modern era of minimally invasive drainage technique, especially in a patient with large abscess, diffusely distributed in the abdomen with clinical deterioration. Furthermore, lack of facilities and expertise for minimally invasive techniques pose a challenge in drainage of pancreatic abscess in a resource-limited setting.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 8. | van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502. |
| 9. | Ross A, Gluck M, Irani S, Hauptmann E, Fotoohi M, Siegal J, et al. Combined endoscopic and percutaneous drainage of organized pancreatic necrosis. Gastrointest Endosc 2010;71:79-84. |
| 10. | Gluck M, Ross A, Irani S, Lin O, Gan SI, Fotoohi M, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012;16:248-56. |
| 11. | Darrivere L, Lapidus N, Colignon N, Chafai N, Chaput U, Verdonk F, et al. Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: An observational study. Crit Care 2018;22:321. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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