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Revision as of 14:51, 13 February 2017

Overview

Pancreatic abscess is an unusual and rare, but life threatening complication of acute pancreatitis. It develop 5 weeks after the onset of pancreatitis and after onset of symptoms and subsidence of the acute phase of pancreatitis.[1] It is the most dangerous complication and the most common cause of death for acute pancreatitis.[2][3]

Definition

Historical Perspective

Causes

Common Causes

Common organisms causing pancreatic abscess are as follows:[4]

Aerobic bacteria

  • Enterococcus
  • Escherichia coli
  • Klebsiella pneumoniae
  • Pseudomonas aeruginosa
  • Staphylococcus aureus
  • Proteus

Anaerobic bacteria

  • Bacteriodes fragilis
  • Clostridium perfringens

Differentiating Pancreatic Abscess from other Diseases

Pancreatic abscess should be diagnosed early and treat promptly not only to reduce morbidity and mortality, but also it is important to differentiate from other pancreatic disesases such recurrent pancreatitis, pancreatic psuedocysts etc. as the undrained abscess carreies high risk of mortality.[5][6]

  • Recurrent pancreatitis

Pancreatic necrosis CT findings: Well marginated zones of non-enhanced pancreatic parenchyma Pancreatic abscess CT findings: Absent or limited necrosis Infected pseudocyst

Characteristics Pancreatic abscess Infected pancreatic pseudocyst Infected necrotic pancreas Recurrent pancreatitis
Definition Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas. Necrotic pancreas defined as a diffuse bacterial inflammation of necrotic pancreatic and peripancreatic tissue, but without any significant pus collections
Presentation Present after onset of symptoms and after subsidence of the acute phase of pancreatitls clinically evident during the early phase of acute pancreatitis with signs of sepsis
Laboratory Findings
Prognosis Mortality is high compared to pancreatic abscess

Epidemiology and Demographics

Prevalence

Incidence

Incidence of pancreatic abscess is unknown, but McClave et al reported it as 2-5% among patients hospitalized for pancreatitis.[7]

Case Fatality Rate

Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59%.[8]

Age

Gender

Race

Developed Countries

Developing Countries

Risk Factors

  • History of alcoholic pancreatitis who fails to respond to medical therapy[4][9]

Natural History, Complications and Prognosis

Complications

  • Intra abdominal sepsis
  • Peritonitis
  • Septicemia
  • Renal failure
  • Pleural effusion
  • Bronchopneumonia
  • Atelectasis
  • Pulmonary embolus
  • Hepatic failure

Gastric complications

  • GI bleeding
  • Gastric outlet obstruction

Colon complications

  • Colonic fistula

Other complications

  • Pancreatic fistula
  • Pancreaticocolocutaneous fistula
  • Wound infection
  • Recurrent abdominal pain
  • Duodenal fistula

Association

  • Biliary tract disease
  • Alcohol addiction
  • Carcinoma
  • Peptic ulcer
  • Trauma
  • Polyarteritis nodosa

Diagnosis

History and Symptoms

Common Symptoms

Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:[4]

Less common symptoms

Vital signs

  • High grade fever (greater than 37.8°C)
  • Upper abdominal pain
  • Failure to thrive

Physical Examination Findings

  • Abdominal tenderness[4]
  • Abdominal mass
  • Abdominal distention

Lab Findings

  • Leukocytosis (range between 10,500 to 35,00O/mm3)

Imaging

Imaging studies are crucial in the diagnosis and treatment of pancreatic abscess.

X-ray

  • Shows extraluminal (pancreas or lesser sac) gas bubbles suggesting abscess[9]
  • Disclosed pleural effusion[10]
  • Diaphragmatic elevation
  • Basilar atelectasis

Ultrasound

  • Shows fluid filled sac suggesting abscess

Treatment

Surgical Therapy

Transpapillary Drainage

Endoscopic Drainage

Indications

  • Patients who are unfit for surgical drainage.

Advantages

  • Less invasive
  • Potentially safe

References

  1. Bittner R, Block S, Büchler M, Beger HG (1987). "Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis". Dig Dis Sci. 32 (10): 1082–7. PMID 3308374.
  2. Bolooki H, Jaffe B, Gliedman ML (1968). "Pancreatic abscesses and lesser omental sac collections". Surg Gynecol Obstet. 126 (6): 1301–8. PMID 5652669.
  3. Ranson JH, Balthazar E, Caccavale R, Cooper M (1985). "Computed tomography and the prediction of pancreatic abscess in acute pancreatitis". Ann Surg. 201 (5): 656–65. PMC 1250783. PMID 3994437.
  4. 4.0 4.1 4.2 4.3 Aranha GV, Prinz RA, Greenlee HB (1982). "Pancreatic abscess: an unresolved surgical problem". Am J Surg. 144 (5): 534–8. PMID 7137463.
  5. ALTEMEIER WA, ALEXANDER JW (1963). "Pancreatic abscess. A study of 32 cases". Arch Surg. 87: 80–9. PMID 14012297.
  6. Bittner R, Block S, Büchler M, Beger HG (1987). "Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis". Dig Dis Sci. 32 (10): 1082–7. PMID 3308374.
  7. McClave SA, McAllister EW, Karl RC, Nord HJ (1986). "Pancreatic abscess: 10-year experience at the University of South Florida". Am J Gastroenterol. 81 (3): 180–4. PMID 3513543.
  8. Neoptolemos JP, Raraty M, Finch M, Sutton R (1998). "Acute pancreatitis: the substantial human and financial costs". Gut. 42 (6): 886–91. PMC 1727149. PMID 9691932.
  9. 9.0 9.1 Miller TA, Lindenauer SM, Frey CF, Stanley JC (1974). "Proceedings: Pancreatic abscess". Arch Surg. 108 (4): 545–51. PMID 4815930.
  10. Camer SJ, Tan EG, Warren KW, Braasch JW (1975). "Pancreatic abscess. A critical analysis of 113 cases". Am J Surg. 129 (4): 426–31. PMID 804826.

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