Pancreatic Abscess

Pancreatic necrosis and Pancreatic Abscess In the characterization of infections in the pancreas, recognizing the different terms used in describing this complication of acute pancreatitis is important

Pancreatic necrosis and Pancreatic Abscess

General Consideration Pancreatic abscesses form through various mechanisms including: ▼ ► penetrating peptic ulcers and ► secondary infection of pseudocysts At any point after the initial injury in acute necrotizing pancreatic (ANP), ►infection of necrotic tissue may occur ► leading to abscess formation

Pancreatic necrosis and Pancreatic Abscess General Consideration ► A pancreatic abscess (PA) is a collection of pus resulting from tissue: necrosis liquefaction and infection ► Infected necrosis refers to bacterial contamination of necrotic pancreatic tissue in the absence of abscess formation

Pancreatic necrosis and Pancreatic Abscess

General Consideration The most typical organisms isolated from infected: necrosis and abscesses are: enteric bacteria and Candida species

►There no evidence that prophylactic antibiotics given early in the course of acute pancreatitis decrease the incidence of abscess

Pancreatic necrosis and Pancreatic Abscess ►A pseudocyst is a peripancreatic fluid collection containing high concentrations of pancreatic enzymes within a defined fibrous wall and lacking an epithelial lining

Pancreatic necrosis and Pancreatic Abscess Pancreatic abscess is a late complication of acute necrotizing pancreatitis (ANP), occurring more than 4 weeks after the initial attack

The mortality rate associated with pancreatic abscess is generally less than that of infected necrosis

Pancreatic necrosis and Pancreatic Abscess Pathophysiology: Remember: ANP is the most severe end of a spectrum of inflammation associated with pancreatitis

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Inflammation causes cell death with resultant devitalized tissue, which is likely to become infected

► The amount of necrotic tissue is the strongest predictor of mortality in ANP

Pancreatic necrosis and Pancreatic Abscess Pathophysiology: After pancreatic necrosis occurs, 3 potential outcomes exist: 1. resolution 2. pseudocyst or 3. abscess Pseudocysts and abscesses can be: single or multiple and vary greatly in size

Pancreatic necrosis and Pancreatic Abscess Sex Differences in sexual predilection are based on the difference in frequency of causative factors of the pancreatitis Causes: ► cholelithiasis and ► alcohol account for more than 80% of cases in the developed world

Pancreatic necrosis and Pancreatic Abscess Causes Superinfection of pseudocysts is one way that pancreatic abscesses may form though pseudocysts are not a prerequisite for abscess formation

►Evidence suggests that colonic translocation of bacterial flora accounts for many cases of pancreatic infection

Clinical findings History ► hemodynamic instability ► fever (39-40 C) ► failure of medical therapy or ► the presence of fluid collections on CT scan and ► WBCC 15-20.000/µL

Pancreatic necrosis and Pancreatic Abscess Clinical findings Physical Pain epigastric pain tenderness and a palpable tender mass are the principal clues to diagnosis Vomiting or jaundice may be present

Pancreatic necrosis and Pancreatic Abscess

Lab findings Serum amylase May be elevated, but usually is normal Serum albumin Is below 2-5g/dL ( normal: 3.4-5.4) Alkaline phosphate is elevated

Pancreatic necrosis and Pancreatic Abscess

Imaging Studies Pleural fluid and diaphragmatic paralysis may be evident on chest x-rays An upper gastrointestinal series usually shows deformity of the: stomach or duodenum by a mass

Pancreatic necrosis and Pancreatic Abscess

Clinical findings Diagnostic ultrasound or CT scanning will usually indicate the presence of a cyst in the area of the pancreas The distinction between: nonifected pseudocyst and pancreatic abscess depends on clinical evidence of suppuration •

Pancreatic necrosis and Pancreatic Abscess

Clinical findings In about 10% of cases, a plain film of the abdomen will reveal gas bubbles (“soap bubble sign”) in the area of the pancreas, a diagnostic finding

In general the diagnosis is difficult, treatment is often instituted late, and morbidity and mortality rate are high

Pancreatic necrosis and Pancreatic Abscess

Complications Fistula formation

Enterocutaneous Entero-entero Enterovascular Recurrent pancreatitis Bowel obstruction

Treatment Medical Care: Medical care generally is supportive, with attention paid to: blood pressure and volume status

Because patients frequently are transiently bacteremic, antibiotics are routinely administered

Treatment Surgical Care Primary drainage of the abscess is the treatment of choice for pancreatic abscess

The standard of care is drainage involving an open procedure

Treatment Surgical Care The goals of operative treatment are to: 1) remove devitalized pancreatic and peripancreatic tissues 2) evacuate all purulent material and provide continuous drainage

Treatment Surgical Care CT, or US-guided percutanuous drainage Marsupialization

Pancreatic necrosis and Pancreatic Abscess Prognosis The mortality rate is about 30%, a consequence of: *the severity of the condition and *the inability in some cases to make the diagnosis

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