Necrotizing pancreatitis

1. What is necrotizing pancreatitis?

• Acute pancreatitis is an acute inflammatory process affecting the pancreatic tissue, which may or may not be accompanied by injury to distant organs.
• Inflammation of the pancreas or peripancreatic tissue is caused by the activation of pancreatic enzymes within the pancreatic tissue itself.
• Necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis of the pancreatic parenchyma or peripancreatic tissue. The necrotic tissue may or may not be accompanied by infection.

2. Causes of acute pancreatitis

• Gallstones, alcohol, and hypertriglyceridemia are the three most common causes.
• Causes of pancreatitis include:
• Gallstones
• Alcohol
• Hypertriglyceridemia
• Trauma
• Pancreatic tumors
• Medications
• Autoimmune diseases
• Snake or scorpion bites
• Following procedures or surgery involving the pancreas…

3. Symptoms

Common symptoms include:

• Upper abdominal pain, which may radiate to the back
• Nausea and vomiting
• Abdominal distension
• Respiratory failure…

4. Diagnosis

Diagnostic criteria: two of the following three criteria must be present:

• Acute pancreatitis-type abdominal pain: sudden onset in the epigastric or periumbilical region, radiating to the back, continuous in nature, gradually increasing in intensity and reaching maximum severity within 30 minutes, lasting ≥ 24 hours. The pain is relieved by sitting and leaning forward or lying on the left side. The pain is accompanied by vomiting and does not improve after vomiting.
• Blood amylase and/or blood lipase levels ≥ 3 times the upper limit of normal
• Imaging findings consistent with acute pancreatitis (abdominal ultrasound, abdominal CT, abdominal MRI)

5. Course of acute pancreatitis

Acute pancreatitis progresses through two phases:

• Phase 1: Related to the pathophysiology of the inflammatory process, this phase usually lasts 1 week. The severity of pancreatitis is associated with extra-pancreatic organ failure resulting from a systemic inflammatory response. Infectious complications are uncommon. Symptoms include fever, hypotension, acute respiratory failure, and leukocytosis due to the systemic inflammatory response. Approximately 75–80% of patients with acute pancreatitis remain stable and do not progress to Phase 2.
• Phase 2: Related to local complications such as pancreatic necrosis (< 20% of patients), this phase lasts from several weeks to several months. Mortality results from a combination of factors, including secondary organ failure following sterile necrosis, infected necrosis, or complications of surgical intervention…

6. Treatment

Principles of acute pancreatitis treatment:

• Pain relief
• Fluid and electrolyte replacement
• Adequate nutritional support
• Management of complications
• Treatment of the underlying cause

Local complications of acute pancreatitis include pancreatic and/or peripancreatic necrosis. The necrosis may be infected or sterile and may cause complications requiring intervention. The timing of intervention for these local complications depends on the stage of the disease.

Early phase: 1–2 weeks after pancreatitis (acute necrotic collection)

• Increased intra-abdominal pressure that does not improve with medical treatment
  • Percutaneous drainage (fluid collections, abscesses…)
  • Laparotomy
• Intestinal necrosis
• Bleeding

Late phase: 3–4 weeks after pancreatitis (walled-off necrosis with infection or complications)

• Drainage
• Removal of necrotic pancreatic tissue

6.1. Preoperative preparation

• General tests: complete blood count, AST, ALT, GGT, total and direct bilirubin, urea, creatinine, amylase, chest X-ray, electrocardiogram, CA 19-9…
• Imaging: contrast-enhanced abdominal CT (computed tomography) to assess pancreatic lesions, the extent of pancreatic necrosis, its spread, and surrounding organs. In some diagnostically challenging cases, magnetic resonance imaging may also be performed.

6.2. Surgery

Depending on the location and extent of pancreatic necrosis and the patient's overall condition, the appropriate procedure or surgical approach is selected.

• Necrosectomy: open surgery or laparoscopy (which may need to be performed multiple times due to the progression of necrosis)
• Endoscopic or transgastric necrosectomy
• Percutaneous intervention: drainage and percutaneous removal of necrotic pancreatic tissue
• Endoscopic removal of necrotic tissue
• Combined step-up approach (drainage followed by necrosectomy)

6.3. Surgical risks

• General risks: cardiovascular and respiratory complications, postoperative bleeding, gastrointestinal leakage…
• Pancreatic fistula and complications following pancreatic fistula: bleeding, pseudoaneurysm, and fistula formation into adjacent organs

6.4. Care and follow-up after drainage or necrosectomy

• After the intervention, patients will have drainage tubes in place to drain fluid and retained tissue resulting from necrosis of the pancreas and peripancreatic tissue.
• The drainage tubes are flushed as indicated by the treating physician.
• Drainage tubes may remain in place for 1–2 weeks, depending on their function and effectiveness.
• Multiple interventions to remove necrotic pancreatic tissue may be required due to the progression of necrosis in the pancreatic and peripancreatic tissues.
• Patients may be discharged when the infection is stable, the full course of antibiotics has been completed, and they are able to eat and drink.
• Patients may be discharged home with drainage tubes and may flush the tubes at home.
• After discharge, patients should seek early medical attention if they experience:
  • Severe abdominal pain that does not respond to pain medication
  • Fever
  • Nausea and vomiting

The information above is for reference purposes only and is not intended as medical advice. Please contact your doctor for detailed medical consultation.