Pancreatic abscess: Difference between revisions

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{{CMG}}; {{AE}}{{VSKP}}
{{CMG}}; {{AE}}{{VSKP}}


'''''Synonyms and Keywords:''''' Abscess of pancreas
{{SK}} Abscess of pancreas<br>
'''To return to abscess main page, click [[Abscess|here]]'''
==Overview==
==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.<ref name="pmid33083742">{{cite journal| author=Bittner R, Block S, Büchler M, Beger HG| title=Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis. | journal=Dig Dis Sci | year= 1987 | volume= 32 | issue= 10 | pages= 1082-7 | pmid=3308374 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3308374  }}</ref> Most of the pancreatic abscesses are developed from the progressive liquefaction of necrotic pancreatic and peri-pancreatic tissues, but some arise from infection of peripancreatic fluid or collections elsewhere in the peritoneal cavity. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal pancreas, an enlargement that is focal or diffuse, mild peripancreatic inflammations or a single collection of fluid (pseudocyst) have less than 2% chances of developing an abscess. However, the probability of developing an abscess increases to nearly 60% in patients with more than two pseudocysts and [[gas]] within the pancreas. Pancreatic abscess is the most dangerous complication and the most common cause of death for acute pancreatitis.<ref name="pmid5652669">{{cite journal| author=Bolooki H, Jaffe B, Gliedman ML| title=Pancreatic abscesses and lesser omental sac collections. | journal=Surg Gynecol Obstet | year= 1968 | volume= 126 | issue= 6 | pages= 1301-8 | pmid=5652669 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5652669  }} </ref><ref name="pmid3994437">{{cite journal| author=Ranson JH, Balthazar E, Caccavale R, Cooper M| title=Computed tomography and the prediction of pancreatic abscess in acute pancreatitis. | journal=Ann Surg | year= 1985 | volume= 201 | issue= 5 | pages= 656-65 | pmid=3994437 | doi= | pmc=1250783 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3994437  }} </ref>
[[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]].<ref name="pmid33083742">{{cite journal| author=Bittner R, Block S, Büchler M, Beger HG| title=Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis. | journal=Dig Dis Sci | year= 1987 | volume= 32 | issue= 10 | pages= 1082-7 | pmid=3308374 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3308374  }}</ref> Most of the pancreatic abscesses are developed from the progressive [[liquefaction]] of [[Necrotic|necrotic pancreatic]] and peri-pancreatic [[tissues]], but some arise from [[infection]] of peri-pancreatic [[fluid]] or collections elsewhere in the [[peritoneal cavity]]. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal [[pancreas]], an enlargement that is focal or diffuse, mild peri-pancreatic [[Inflammation|inflammations]] or a single collection of fluid ([[Pancreatic pseudocyst|pseudocyst]]), have less than 2% chances of developing an [[abscess]]. However, the probability of developing an abscess increases to nearly 60% in patients with more than two [[Pseudocyst|pseudocysts]] and [[gas]] within the [[pancreas]]. [[Pancreatic]] [[abscess]] is the most dangerous complication and the most common cause of death for [[acute pancreatitis]].<ref name="pmid5652669">{{cite journal| author=Bolooki H, Jaffe B, Gliedman ML| title=Pancreatic abscesses and lesser omental sac collections. | journal=Surg Gynecol Obstet | year= 1968 | volume= 126 | issue= 6 | pages= 1301-8 | pmid=5652669 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5652669  }} </ref><ref name="pmid3994437">{{cite journal| author=Ranson JH, Balthazar E, Caccavale R, Cooper M| title=Computed tomography and the prediction of pancreatic abscess in acute pancreatitis. | journal=Ann Surg | year= 1985 | volume= 201 | issue= 5 | pages= 656-65 | pmid=3994437 | doi= | pmc=1250783 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3994437  }} </ref>
==Definition==
==Definition==
Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas.<ref name="pmid8255888">{{cite journal| author=Frey C, Reber HA| title=Clinically based classification system for acute pancreatitis. | journal=Pancreas | year= 1993 | volume= 8 | issue= 6 | pages= 738-40 | pmid=8255888 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8255888  }} </ref>
[[Pancreatic]] [[abscess]] is defined as a localized collection of [[pus]] surrounded by a more or less distinct capsula in inflamed [[pancreas]].<ref name="pmid8255888">{{cite journal| author=Frey C, Reber HA| title=Clinically based classification system for acute pancreatitis. | journal=Pancreas | year= 1993 | volume= 8 | issue= 6 | pages= 738-40 | pmid=8255888 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8255888  }} </ref>
==Historical Perspective==
* First case of pancreatic abscess is described by Carrick H. Robertson in 1908.<ref name="pmid20764267">{{cite journal| author=Robertson CH| title=ACUTE PANCREATITIS FOLLOWED BY PANCREATIC ABSCESS: OPERATION: RECOVERY. | journal=Br Med J | year= 1909 | volume= 1 | issue= 2508 | pages= 211-2 | pmid=20764267 | doi= | pmc=2317898 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20764267  }}</ref>
* Simple and safe method of surgical draining for pancreatic abscess described by Albert J. Ochsner in 1921.<ref name="pmid17864533">{{cite journal| author=Ochsner AJ| title=DRAINAGE OF ABSCESS OF PANCREAS. | journal=Ann Surg | year= 1921 | volume= 74 | issue= 4 | pages= 434 | pmid=17864533 | doi= | pmc=1399727 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17864533  }}</ref>
 
== Pathophysiology ==
Pathogenesis of [[pancreatic]] [[abscesses]] is due to combination of [[ischemic necrosis]] and [[enzymatic]] [[injury]] to the [[Pancreas|pancreatic]] tissue by escaped [[Pancreatic elastase|pancreatic enzymes]].<ref name="pmid686887">{{cite journal| author=Warshaw AL, O'Hara PJ| title=Susceptibility of the pancreas to ischemic injury in shock. | journal=Ann Surg | year= 1978 | volume= 188 | issue= 2 | pages= 197-201 | pmid=686887 | doi= | pmc=1396740 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=686887  }} </ref> Pancreatic abscess is commonly present in 1% to 30% of all patients with clinical [[acute pancreatitis]], but it is more frequetly occurs in up to 50% to 70% of patients with severe necrotizing pancreatitis.<ref name="pmid505247">{{cite journal| author=Frey CF, Lindenauer SM, Miller TA| title=Pancreatic abscess. | journal=Surg Gynecol Obstet | year= 1979 | volume= 149 | issue= 5 | pages= 722-6 | pmid=505247 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=505247  }} </ref><ref name="pmid4597041">{{cite journal| author=Warshaw AL| title=Inflammatory masses following acute pancreatitis. Phlegmon, pseudocyts, and abscess. | journal=Surg Clin North Am | year= 1974 | volume= 54 | issue= 3 | pages= 621-36 | pmid=4597041 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4597041  }} </ref>
 
{| border="2"; style="margin-left: auto; margin-right: auto; border: none;"
|-
|align=center|[[Acute pancreatitis]]
'''⬇'''
 
Necrotizing pancreatitis resulting due to more severe tissue destruction
 
'''⬇'''
 
Increase in intestinal permeability  to [[bacteria]]
 
'''⬇'''
 
Increased rate of infection of the necrotic tissue
 
'''⬇'''
 
Abscess formation
 
|-
|}


==Causes==
==Causes==
===Common Causes===
===Common Causes===
Common organisms causing pancreatic abscess are as follows:<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref>
Common organisms causing pancreatic abscess are as follows:<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref>
 
{| border="1"
'''Aerobic bacteria'''
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Aerobic bacteria}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Anaerobes bacteria}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Fungal}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Parasite}}
|-
|valign=top|
* [[Enterococcus]]   
* [[Enterococcus]]   
* [[Escherichia coli]]   
* [[Escherichia coli]]   
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* [[Staphylococcus aureus]]
* [[Staphylococcus aureus]]
* [[Proteus]]
* [[Proteus]]
'''Anaerobic bacteria'''
|valign=top|
* [[Bacteroides fragilis]]
* [[Bacteroides fragilis]]
* [[Clostridium perfringens]]
* [[Clostridium perfringens]]
|valign=top|
* [[Candida albicans]]
* [[Candida tropicalis]]
|valign=top|
* [[Entamoeba histolytica]]
|}
==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 [[diseases]] such as: [[Pancreatitis|recurrent pancreatitis]] and [[Pancreatic pseudocyst|pancreatic pseudocysts]] as the undrained abscess carreies high risk of mortality.<ref name="pmid14012297">{{cite journal| author=ALTEMEIER WA, ALEXANDER JW| title=Pancreatic abscess. A study of 32 cases. | journal=Arch Surg | year= 1963 | volume= 87 | issue=  | pages= 80-9 | pmid=14012297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14012297  }} </ref><ref name="pmid3308374">{{cite journal| author=Bittner R, Block S, Büchler M, Beger HG| title=Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis. | journal=Dig Dis Sci | year= 1987 | volume= 32 | issue= 10 | pages= 1082-7 | pmid=3308374 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3308374  }} </ref><ref name="pmid33083743">{{cite journal| author=Bittner R, Block S, Büchler M, Beger HG| title=Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis. | journal=Dig Dis Sci | year= 1987 | volume= 32 | issue= 10 | pages= 1082-7 | pmid=3308374 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3308374  }}</ref>
{| border="1"
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Characteristics'''}}
! style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Pancreatic abscess'''}}
! style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Infected pancreatic pseudocyst'''}}
! style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Infected necrotic pancreas'''}}
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Definition'''}}
|Pancreatic abscess is defined as a localized collection of [[pus]] surrounded by a more or less distinct capsula in inflamed [[pancreas]].
|[[Pancreatic]] [[pseudocyst]] is defined as a collection of [[pancreatic juice]] enclosed by a non-epithelialized wall, that developed as a complication of [[acute pancreatitis]], pancreatic trauma, or [[chronic pancreatitis]].
|[[Necrotic]] [[pancreas]] defined as a diffuse [[bacterial]] [[inflammation]] of necrotic pancreatic and peri-pancreatic tissue but without any significant [[pus]] collections
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Presentation'''}}
|Present after onset of symptoms and after subsidence of the acute phase of [[pancreatitis]]
|Present after 5 weeks of [[acute pancreatitis]]
|clinically evident during the early phase of [[acute pancreatitis]] with signs of [[sepsis]]
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Pathology'''}}
|[[Pancreatic abscess]] contains [[pus]] with viable [[bacteria]] or [[Fungus|fungi]] and little or no [[pancreatic]] [[necrosis]]. This pathology differentiates abscess from infected [[necrosis]].
|Presence of well-defined wall composed of [[Granulation tissue|granulation]] or [[fibrous tissue]] that distinguishes a [[pseudocyst]] from an acute [[fluid]] collection ([[cyst]]). The fluid is usually rich in pancreatic [[enzymes]] and is most often [[sterile]].
|Pathology shows areas of devitalized pancreatic [[parenchyma]] and peri-pancreatic [[fat]] necrosis.
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Laboratory Findings'''}}
|
* Hyperamylasemia
* [[Hypocalcemia]] (Ca <8 mg/dl)


== Pathophysiology ==
* [[Blood glucose]] >200 mg/dl
Pathogenesis of pancreatic abscesses is due to combination of ischemic necrosis and enzymatic injury to the pancreatic tissue by escaped pancreatic enzymes.<ref name="pmid686887">{{cite journal| author=Warshaw AL, O'Hara PJ| title=Susceptibility of the pancreas to ischemic injury in shock. | journal=Ann Surg | year= 1978 | volume= 188 | issue= 2 | pages= 197-201 | pmid=686887 | doi= | pmc=1396740 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=686887  }} </ref>
* [[Lactate dehydrogenase|LDH]] >350 units/liter
|
* Serum findings have limited use
* Mild increase in [[amylase]], [[lipase]] levels but with in the reference range
* Mild elevation in [[Liver function tests|LFT]].
|
* [[Lactate dehydrogenase|LDH]] >350 units/liter
* [[Hypocalcemia]] (Ca <8 mg/dl)
* Blood glucose >200 mg/dl
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''CT Findings'''}}
|Absent or limited [[necrosis]] with [[pus]]
|Pancreatic [[pseudocyst]] with a well defined rounded cystic lesion is seen
|Well marginated zones of non-enhanced pancreatic parenchyma
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Prognosis'''}}
|Mortality rate of pancreatic abscess is varies depending upon the severity of [[pancreatitis]] with range of 10-59%
|
|Mortality is high compared to [[pancreatic abscess]]
|}


==Epidemiology and Demographics==
==Epidemiology and Demographics==
=== Prevalence ===
=== Incidence ===
=== Incidence ===
Incidence of pancreatic abscess is unknown, but McClave et al reported it as 2-5% among patients hospitalized for pancreatitis.<ref name="pmid3513543">{{cite journal| author=McClave SA, McAllister EW, Karl RC, Nord HJ| title=Pancreatic abscess: 10-year experience at the University of South Florida. | journal=Am J Gastroenterol | year= 1986 | volume= 81 | issue= 3 | pages= 180-4 | pmid=3513543 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3513543  }} </ref>
Incidence of pancreatic abscess is unknown, but McClave et al reported it as 2-5% among patients hospitalized for [[pancreatitis]].<ref name="pmid3513543">{{cite journal| author=McClave SA, McAllister EW, Karl RC, Nord HJ| title=Pancreatic abscess: 10-year experience at the University of South Florida. | journal=Am J Gastroenterol | year= 1986 | volume= 81 | issue= 3 | pages= 180-4 | pmid=3513543 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3513543  }} </ref>
=== Case Fatality Rate ===
=== Case Fatality Rate ===
Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59%.<ref name="pmid9691932">{{cite journal| author=Neoptolemos JP, Raraty M, Finch M, Sutton R| title=Acute pancreatitis: the substantial human and financial costs. | journal=Gut | year= 1998 | volume= 42 | issue= 6 | pages= 886-91 | pmid=9691932 | doi= | pmc=1727149 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9691932  }} </ref>
Mortality rate of pancreatic abscess is varies depending upon the severity of [[pancreatitis]] with range of 10-59%.<ref name="pmid9691932">{{cite journal| author=Neoptolemos JP, Raraty M, Finch M, Sutton R| title=Acute pancreatitis: the substantial human and financial costs. | journal=Gut | year= 1998 | volume= 42 | issue= 6 | pages= 886-91 | pmid=9691932 | doi= | pmc=1727149 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9691932  }} </ref>
=== Age ===
=== Age & Gender ===
=== Gender ===
No age and gender predilection for pancreatic abscess.
 
=== Race ===
=== Race ===
=== Developed Countries ===
Pancreatic abscess has no race predilection.
=== Developing Countries ===
 
==Risk Factors==
==Risk Factors==
Spleen abscess often co-exists with several risk factors, but the major one is the acute pancreatitis.<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref> Common risk factors of pancreatic abscess include:<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref><ref name="pmid4815930">{{cite journal| author=Miller TA, Lindenauer SM, Frey CF, Stanley JC| title=Proceedings: Pancreatic abscess. | journal=Arch Surg | year= 1974 | volume= 108 | issue= 4 | pages= 545-51 | pmid=4815930 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4815930  }} </ref>
Pancreatic abscess often co-exists with several risk factors, but the major one is the [[acute pancreatitis]].<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref> Common risk factors of [[pancreatic abscess]] include:<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref><ref name="pmid4815930">{{cite journal| author=Miller TA, Lindenauer SM, Frey CF, Stanley JC| title=Proceedings: Pancreatic abscess. | journal=Arch Surg | year= 1974 | volume= 108 | issue= 4 | pages= 545-51 | pmid=4815930 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4815930  }} </ref>
{| border="1"
{| border="1"
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Common risk factors}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Common risk factors}}
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* [[Septicemia]]
* [[Septicemia]]
* [[Pancreatic fistula]]
* [[Pancreatic fistula]]
* [[Pancreatic abscess|Recurrent pancreatic abscess]]
* [[abscess|Recurrent pancreatic abscess]]
|valign=top|
|valign=top|
* [[Pleural effusion]]
* [[Pleural effusion]]
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|valign=top|
|valign=top|
* [[Fistula|Pancreaticocolocutaneous fistula]]
* [[Fistula|Pancreaticocolocutaneous fistula]]
* Wound infection
* [[Wound]] [[infection]]
* [[Fistula|Duodenal fistula]]
* [[Fistula|Duodenal fistula]]
* [[Renal failure]]
* [[Renal failure]]
Line 89: Line 176:


===Prognosis===
===Prognosis===
Prognosis of pancreatic abscess depends on the time of diagnosis and treatment. Outcome of pancreatic abscess is generally based on the severity of the infection. It is however a severe complication which may result in the death of the patient if the appropriate treatment is not administered. Patients are at risk of sepsis and multiple organ failure and in patients with delay in surgery to remove infected abscess, the mortality rate can get to 100%.<ref name="pmid6438821">{{cite journal| author=Bradley EL, Fulenwider JT| title=Open treatment of pancreatic abscess. | journal=Surg Gynecol Obstet | year= 1984 | volume= 159 | issue= 6 | pages= 509-13 | pmid=6438821 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6438821  }} </ref>
Prognosis of [[pancreatic abscess]] depends on the time of diagnosis and treatment. Outcome of pancreatic abscess is generally based on the severity of the [[infection]]. It is however a severe complication which may result in the death of the patient if the appropriate treatment is not administered. Patients are at risk of [[sepsis]] and multiple organ failure and in patients with delay in surgery to remove infected [[abscess]], the mortality rate can get to 100%.<ref name="pmid6438821">{{cite journal| author=Bradley EL, Fulenwider JT| title=Open treatment of pancreatic abscess. | journal=Surg Gynecol Obstet | year= 1984 | volume= 159 | issue= 6 | pages= 509-13 | pmid=6438821 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6438821  }} </ref>


'''Poor prognostic factors'''
'''Poor prognostic factors'''
* Delayed diagnosis
* Delayed diagnosis
* Delayed surgical drainage
* Delayed surgical drainage
* Improper antibiotic use
* Improper [[antibiotic]] use
* [[Alcohol abuse|Alcohol addiction]]
* [[Alcohol abuse|Alcohol addiction]]


==Diagnosis==
==Diagnosis==
As the clinical presentation of pancreatic abscess is variable or even obscure, it should be considered in any febrile patient even 2 weeks after an attack of acute pancreatitis, even in the absence of other symptoms. Most patients who develop pancreatic abscesses have had pancreatitis, so a complete [[medical history]] is required as a first step in diagnosing abscesses.
As the clinical presentation of [[pancreatic abscess]] is variable or even obscure, it should be considered in any [[febrile]] patient even 2 weeks after an attack of [[acute pancreatitis]], even in the absence of other symptoms. Most patients who develop pancreatic abscesses have had [[pancreatitis]], so a complete [[medical history]] is required as a first step in diagnosing abscesses.
===History and Symptoms===
===History and Symptoms===
Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref>
Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref>
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===Physical Examination Findings===
===Physical Examination Findings===
===Appearance===
===Appearance===
Patient with splenic abscess appear ill appearing and [[diaphoretic]]
Patient with pancreatic abscess appears ill and [[diaphoretic]]
 
===Vital signs===
===Vital signs===
* [[Fever|High-grade fever]] (greater than 37.8°C)
* [[Fever|High-grade fever]] (greater than 37.8°C)
* [[Hyperthermia]]
* [[Tachycardia]]
* [[Tachycardia]]
If patient present with sepsis:  
If patient present with sepsis:  
Line 127: Line 214:
* [[Tachycardia]]
* [[Tachycardia]]
* Increased [[capillary refill time]]
* Increased [[capillary refill time]]
===Heart===
===Heart===
* No specific cardiovascular findings related to pancreatic abscess.
* No specific cardiovascular findings related to pancreatic abscess.
===Lungs===
===Lungs===
Left sided pleural effusion may be present with signs of:
Left sided [[pleural effusion]] may be present with signs of:
* Decreased [[breath sounds]] on left side
* Decreased [[breath sounds]] on left side
* Dullness to percussion on left side
* Dullness to percussion on left side
Line 138: Line 226:
===Abdomen ===
===Abdomen ===
'''Palpation'''
'''Palpation'''
* Abdominal tenderness<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref>
* [[Abdominal tenderness]]<ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref>
* Palpable abdominal mass
* Palpable [[abdominal mass]]
* Abdominal distention  
* [[Abdominal distention]]
===Lab Findings===
===Lab Findings===
====Blood Tests====
====Blood Tests====
* '''CBC with differential:''' Leukocytosis (range between 10,500 to 35,00O/mm<sup>3</sup>)
* '''CBC with differential:''' [[Leukocytosis]] (range between 10,500 to 35,00O/mm<sup>3</sup>)
* '''Blood culture:''' Low sensitivity to diagnose causative organism in pancreatic abscess as shows positivity in few cases, but it helps to distinguish abscesses from sterile pseudocysts and provide guidance for selection of antibiotics.<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref>
* '''Blood culture:''' Low sensitivity to diagnose causative organism in [[pancreatic]] [[abscess]] as shows positivity in few cases, but it helps to distinguish abscesses from [[sterile]] [[Pseudocyst|pseudocysts]] and provide guidance for selection of [[antibiotics]].<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref>
===Fine Needle Aspiration===
===Fine Needle Aspiration===
'''Advantages'''
'''Advantages'''
* Fine needle aspiration can distinguish sterile inflammation from infection and it is the procedure of choice in the verification of bacterial infection.<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref>
* Fine [[needle]] [[aspiration]] can distinguish sterile [[inflammation]] from [[infection]] and it is the procedure of choice in the verification of [[bacterial infection]].<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref>
* High sensitivity of 90% to 100%
* High sensitivity of 90% to 100%
* Low complication rate
* Low complication rate
* It aid in the early diagnosis of infectious complications of pancreatic abscess and to avoid unnecessary laparotomy.
* It aid in the early diagnosis of [[infectious]] complications of pancreatic abscess and to avoid unnecessary [[laparotomy]].


===Imaging===
===Imaging===
Imaging studies are crucial in the diagnosis and treatment of pancreatic abscess.
Imaging studies are crucial in the diagnosis and treatment of pancreatic abscess. Both [[ultrasonography]] and [[computed tomography]] (CT) can be helpful with the diagnosis and localization of pancreatic abscesses, which may extend from the [[pancreas]] anywhere (e.g. [[retroperitoneum]], [[mesentery]], [[mediastinum]], and even the neck or [[genitalia]]).<ref name="pmid3994437">{{cite journal| author=Ranson JH, Balthazar E, Caccavale R, Cooper M| title=Computed tomography and the prediction of pancreatic abscess in acute pancreatitis. | journal=Ann Surg | year= 1985 | volume= 201 | issue= 5 | pages= 656-65 | pmid=3994437 | doi= | pmc=1250783 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3994437  }} </ref><ref name="pmid1898576">{{cite journal| author=Johnson CD, Stephens DH, Sarr MG| title=CT of acute pancreatitis: correlation between lack of contrast enhancement and pancreatic necrosis. | journal=AJR Am J Roentgenol | year= 1991 | volume= 156 | issue= 1 | pages= 93-5 | pmid=1898576 | doi=10.2214/ajr.156.1.1898576 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1898576  }} </ref>
Both ultrasonography and computed tomography (CT) can be helpful with the diagnosis and localization of pancreatic abscesses, which may extend from the pancreas anywhere (e.g. retroperitoneum, mesentery, mediastinum, and even the neck or genitalia).<ref name="pmid3994437">{{cite journal| author=Ranson JH, Balthazar E, Caccavale R, Cooper M| title=Computed tomography and the prediction of pancreatic abscess in acute pancreatitis. | journal=Ann Surg | year= 1985 | volume= 201 | issue= 5 | pages= 656-65 | pmid=3994437 | doi= | pmc=1250783 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3994437  }} </ref><ref name="pmid1898576">{{cite journal| author=Johnson CD, Stephens DH, Sarr MG| title=CT of acute pancreatitis: correlation between lack of contrast enhancement and pancreatic necrosis. | journal=AJR Am J Roentgenol | year= 1991 | volume= 156 | issue= 1 | pages= 93-5 | pmid=1898576 | doi=10.2214/ajr.156.1.1898576 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1898576  }} </ref>
====X-ray====
====X-ray====
* Shows extraluminal (pancreas or lesser sac) gas bubbles suggesting abscess<ref name="pmid4815930">{{cite journal| author=Miller TA, Lindenauer SM, Frey CF, Stanley JC| title=Proceedings: Pancreatic abscess. | journal=Arch Surg | year= 1974 | volume= 108 | issue= 4 | pages= 545-51 | pmid=4815930 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4815930  }} </ref>
* Shows extraluminal ([[pancreas]] or [[lesser sac]]) [[gas]] bubbles suggesting abscess<ref name="pmid4815930">{{cite journal| author=Miller TA, Lindenauer SM, Frey CF, Stanley JC| title=Proceedings: Pancreatic abscess. | journal=Arch Surg | year= 1974 | volume= 108 | issue= 4 | pages= 545-51 | pmid=4815930 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4815930  }} </ref>
* Disclosed pleural effusion<ref name="pmid804826">{{cite journal| author=Camer SJ, Tan EG, Warren KW, Braasch JW| title=Pancreatic abscess. A critical analysis of 113 cases. | journal=Am J Surg | year= 1975 | volume= 129 | issue= 4 | pages= 426-31 | pmid=804826 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=804826  }} </ref>
* Disclosed [[pleural effusion]]<ref name="pmid804826">{{cite journal| author=Camer SJ, Tan EG, Warren KW, Braasch JW| title=Pancreatic abscess. A critical analysis of 113 cases. | journal=Am J Surg | year= 1975 | volume= 129 | issue= 4 | pages= 426-31 | pmid=804826 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=804826  }} </ref>
* Diaphragmatic elevation
* [[Diaphragmatic elevation]]
* Basilar atelectasis
* [[Atelectasis|Basilar atelectasis]]
====Ultrasound====
====Ultrasound====
* Shows fluid filled sac suggesting abscess
* Shows [[fluid]] filled sac suggesting abscess
====CT====
====CT====
CT had a sensitivity of 74%, compared with 35% for ultrasound in the diagnosis of pancreatic abscess.<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref>
CT had a sensitivity of 74%, compared with 35% for ultrasound in the diagnosis of pancreatic abscess.<ref name="pmid8995072">{{cite journal| author=Mithöfer K, Mueller PR, Warshaw AL| title=Interventional and surgical treatment of pancreatic abscess. | journal=World J Surg | year= 1997 | volume= 21 | issue= 2 | pages= 162-8 | pmid=8995072 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8995072  }} </ref>
'''CT of Pancreatic abscess'''
[[File:Pancreatic abscess.gif|800px|thumb|center|Case courtesy of Dr  Mohammad Taghi Niknejad, Radiopaedia.org, rID: 20938]]
'''CT of Pancreatic psuedocyst'''
[[File:Pancreatic psuedocyst.gif|800px|thumb|center|Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 25280]]


==Treatment==
==Treatment==
[[Antibiotics]] are commonly used as a curing method for pancreatic abscesses although their role remains controversial. Prophylactic antibiotics are normally chosen based on the type of flora and the degree of antibiotic penetration into the abscess. Pancreatic abscesses are more likely to host enteric organisms and pathogens such as ''[[E. coli]]'', ''[[Klebsiella pneumonia]]'', ''[[Enterococcus faecalis]]'', ''[[Staphylococcus aureus]]'', ''[[Pseudomonas aeruginosa]]'', ''[[Proteus mirabilis]]'', and ''[[Streptococcus]]'' species. Medical therapy is usually given to people whose general health status does not allow surgery. On the other hand, antibiotics are not recommended in patients with pancreatitis, unless the presence of an infected abscess has been proved.
===Medical Therapy===
[[Antibiotics]] are commonly used as a curing method for [[pancreatic]] [[abscesses]] although their role remains controversial. Prophylactic antibiotics are normally chosen based on the type of flora and the degree of antibiotic penetration into the [[abscess]].<ref name="pmid804826">{{cite journal| author=Camer SJ, Tan EG, Warren KW, Braasch JW| title=Pancreatic abscess. A critical analysis of 113 cases. | journal=Am J Surg | year= 1975 | volume= 129 | issue= 4 | pages= 426-31 | pmid=804826 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=804826  }} </ref> Pancreatic abscesses are more likely to host enteric [[organisms]] and [[pathogens]] such as ''[[E. coli]]'', ''[[Klebsiella pneumoniae|Klebsiella pneumonia]]'', ''[[Enterococcus faecalis]]'', ''[[Staphylococcus aureus]]'', ''[[Pseudomonas aeruginosa]]'', ''[[Proteus mirabilis]]'', and ''[[Streptococcus]]'' species. Medical therapy is usually given to people whose general health status does not allow surgery. On the other hand, antibiotics are not recommended in patients with [[pancreatitis]], unless the presence of an infected abscess has been proved.


Although there have been reported cases of patients who were given medical treatment and survived, primary [[drainage]] of the abscess is the main treatment used to cure this condition. Drainage usually involves a surgical procedure. It has been shown that CT-guided drainage brought inferior results than open drainage. Hence, open surgical procedure is preferred to successfully remove the abscess. However, CT-guided drainage is the option treatment for patients who may not tolerate an open procedure. Endoscopic treatment is at the same time a treatment option that increased in popularity over the last years.
=== Surgical Therapy ===
Surgical therapy is the traditional method of treatment of pancreatic abscesses, usually by inserting one or more non-traumatic drains through trans-peritoneal or through [[flank]] or [[retroperitoneum]] into the [[abscess]] cavity. Although there have been reported cases of patients who were given medical treatment and survived, primary [[drainage]] of the [[abscess]] is the main treatment used to cure this condition. Drainage usually involves a [[surgical procedure]]. It has been shown that CT-guided drainage brought inferior results than open drainage.<ref name="pmid6770619">{{cite journal| author=Siegelman SS, Copeland BE, Saba GP, Cameron JL, Sanders RC, Zerhouni EA| title=CT of fluid collections associated with pancreatitis. | journal=AJR Am J Roentgenol | year= 1980 | volume= 134 | issue= 6 | pages= 1121-32 | pmid=6770619 | doi=10.2214/ajr.134.6.1121 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6770619  }} </ref> Hence, open surgical procedure is preferred to successfully remove the abscess. However, CT-guided drainage is the option treatment for patients who may not tolerate an open procedure. [[Endoscopic]] treatment is at the same time a treatment option that increased in popularity over the last years. Failure of the surgical drainage might be due to the reluctance to expose the cavity widely and to debride the necrotic components aggressively.<ref name="pmid11818936">{{cite journal| author=Park JJ, Kim SS, Koo YS, Choi DJ, Park HC, Kim JH et al.| title=Definitive treatment of pancreatic abscess by endoscopic transmural drainage. | journal=Gastrointest Endosc | year= 2002 | volume= 55 | issue= 2 | pages= 256-62 | pmid=11818936 | doi=10.1067/mge.2002.120887 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11818936  }} </ref><ref name="pmid7137463">{{cite journal| author=Aranha GV, Prinz RA, Greenlee HB| title=Pancreatic abscess: an unresolved surgical problem. | journal=Am J Surg | year= 1982 | volume= 144 | issue= 5 | pages= 534-8 | pmid=7137463 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7137463  }} </ref> For a detailed approach on performing surgical drainage of pancreatic abscess watch the video below:
{{#ev:youtube|v=H7Rxybb406A}}


==Prevention==
==Prevention==
In some cases, abscesses may be prevented by draining an existing pseudocyst which is likely to become inflamed. However, in most cases the developing of abscesses cannot be prevented.
In some cases, [[abscesses]] may be prevented by draining an existing [[pseudocyst]] which is likely to become inflamed. However, in most cases the developing of abscesses cannot be prevented.


==References==
==References==
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[[Category:Pancreas disorders]]
[[Category:Pancreas disorders]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Up-To-Date]]
[[Category:Gastroenterology]]
[[Category:Surgery]]

Latest revision as of 23:32, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Synonyms and keywords: Abscess of pancreas
To return to abscess main page, click here

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] Most of the pancreatic abscesses are developed from the progressive liquefaction of necrotic pancreatic and peri-pancreatic tissues, but some arise from infection of peri-pancreatic fluid or collections elsewhere in the peritoneal cavity. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal pancreas, an enlargement that is focal or diffuse, mild peri-pancreatic inflammations or a single collection of fluid (pseudocyst), have less than 2% chances of developing an abscess. However, the probability of developing an abscess increases to nearly 60% in patients with more than two pseudocysts and gas within the pancreas. Pancreatic abscess is the most dangerous complication and the most common cause of death for acute pancreatitis.[2][3]

Definition

Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas.[4]

Historical Perspective

  • First case of pancreatic abscess is described by Carrick H. Robertson in 1908.[5]
  • Simple and safe method of surgical draining for pancreatic abscess described by Albert J. Ochsner in 1921.[6]

Pathophysiology

Pathogenesis of pancreatic abscesses is due to combination of ischemic necrosis and enzymatic injury to the pancreatic tissue by escaped pancreatic enzymes.[7] Pancreatic abscess is commonly present in 1% to 30% of all patients with clinical acute pancreatitis, but it is more frequetly occurs in up to 50% to 70% of patients with severe necrotizing pancreatitis.[8][9]

Acute pancreatitis

Necrotizing pancreatitis resulting due to more severe tissue destruction

Increase in intestinal permeability to bacteria

Increased rate of infection of the necrotic tissue

Abscess formation

Causes

Common Causes

Common organisms causing pancreatic abscess are as follows:[10]

Aerobic bacteria Anaerobes bacteria Fungal Parasite

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 diseases such as: recurrent pancreatitis and pancreatic pseudocysts as the undrained abscess carreies high risk of mortality.[11][12][13]

Characteristics Pancreatic abscess Infected pancreatic pseudocyst Infected necrotic pancreas
Definition Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas. Pancreatic pseudocyst is defined as a collection of pancreatic juice enclosed by a non-epithelialized wall, that developed as a complication of acute pancreatitis, pancreatic trauma, or chronic pancreatitis. Necrotic pancreas defined as a diffuse bacterial inflammation of necrotic pancreatic and peri-pancreatic tissue but without any significant pus collections
Presentation Present after onset of symptoms and after subsidence of the acute phase of pancreatitis Present after 5 weeks of acute pancreatitis clinically evident during the early phase of acute pancreatitis with signs of sepsis
Pathology Pancreatic abscess contains pus with viable bacteria or fungi and little or no pancreatic necrosis. This pathology differentiates abscess from infected necrosis. Presence of well-defined wall composed of granulation or fibrous tissue that distinguishes a pseudocyst from an acute fluid collection (cyst). The fluid is usually rich in pancreatic enzymes and is most often sterile. Pathology shows areas of devitalized pancreatic parenchyma and peri-pancreatic fat necrosis.
Laboratory Findings
  • Serum findings have limited use
  • Mild increase in amylase, lipase levels but with in the reference range
  • Mild elevation in LFT.
CT Findings Absent or limited necrosis with pus Pancreatic pseudocyst with a well defined rounded cystic lesion is seen Well marginated zones of non-enhanced pancreatic parenchyma
Prognosis Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59% Mortality is high compared to pancreatic abscess

Epidemiology and Demographics

Incidence

Incidence of pancreatic abscess is unknown, but McClave et al reported it as 2-5% among patients hospitalized for pancreatitis.[14]

Case Fatality Rate

Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59%.[15]

Age & Gender

No age and gender predilection for pancreatic abscess.

Race

Pancreatic abscess has no race predilection.

Risk Factors

Pancreatic abscess often co-exists with several risk factors, but the major one is the acute pancreatitis.[16] Common risk factors of pancreatic abscess include:[10][17]

Common risk factors Less common risk factors

Natural History, Complications and Prognosis

Complications

Common complications Respiratory complications Gastric complications Colon complications Other complications

Prognosis

Prognosis of pancreatic abscess depends on the time of diagnosis and treatment. Outcome of pancreatic abscess is generally based on the severity of the infection. It is however a severe complication which may result in the death of the patient if the appropriate treatment is not administered. Patients are at risk of sepsis and multiple organ failure and in patients with delay in surgery to remove infected abscess, the mortality rate can get to 100%.[18]

Poor prognostic factors

Diagnosis

As the clinical presentation of pancreatic abscess is variable or even obscure, it should be considered in any febrile patient even 2 weeks after an attack of acute pancreatitis, even in the absence of other symptoms. Most patients who develop pancreatic abscesses have had pancreatitis, so a complete medical history is required as a first step in diagnosing abscesses.

History and Symptoms

Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:[10]

Common Symptoms Less Common Symptoms

Physical Examination Findings

Appearance

Patient with pancreatic abscess appears ill and diaphoretic

Vital signs

If patient present with sepsis:

Heart

  • No specific cardiovascular findings related to pancreatic abscess.

Lungs

Left sided pleural effusion may be present with signs of:

Abdomen

Palpation

Lab Findings

Blood Tests

Fine Needle Aspiration

Advantages

Imaging

Imaging studies are crucial in the diagnosis and treatment of pancreatic abscess. Both ultrasonography and computed tomography (CT) can be helpful with the diagnosis and localization of pancreatic abscesses, which may extend from the pancreas anywhere (e.g. retroperitoneum, mesentery, mediastinum, and even the neck or genitalia).[3][19]

X-ray

Ultrasound

  • Shows fluid filled sac suggesting abscess

CT

CT had a sensitivity of 74%, compared with 35% for ultrasound in the diagnosis of pancreatic abscess.[16]

CT of Pancreatic abscess

Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 20938

CT of Pancreatic psuedocyst

Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 25280

Treatment

Medical Therapy

Antibiotics are commonly used as a curing method for pancreatic abscesses although their role remains controversial. Prophylactic antibiotics are normally chosen based on the type of flora and the degree of antibiotic penetration into the abscess.[20] Pancreatic abscesses are more likely to host enteric organisms and pathogens such as E. coli, Klebsiella pneumonia, Enterococcus faecalis, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, and Streptococcus species. Medical therapy is usually given to people whose general health status does not allow surgery. On the other hand, antibiotics are not recommended in patients with pancreatitis, unless the presence of an infected abscess has been proved.

Surgical Therapy

Surgical therapy is the traditional method of treatment of pancreatic abscesses, usually by inserting one or more non-traumatic drains through trans-peritoneal or through flank or retroperitoneum into the abscess cavity. Although there have been reported cases of patients who were given medical treatment and survived, primary drainage of the abscess is the main treatment used to cure this condition. Drainage usually involves a surgical procedure. It has been shown that CT-guided drainage brought inferior results than open drainage.[21] Hence, open surgical procedure is preferred to successfully remove the abscess. However, CT-guided drainage is the option treatment for patients who may not tolerate an open procedure. Endoscopic treatment is at the same time a treatment option that increased in popularity over the last years. Failure of the surgical drainage might be due to the reluctance to expose the cavity widely and to debride the necrotic components aggressively.[22][10] For a detailed approach on performing surgical drainage of pancreatic abscess watch the video below: {{#ev:youtube|v=H7Rxybb406A}}

Prevention

In some cases, abscesses may be prevented by draining an existing pseudocyst which is likely to become inflamed. However, in most cases the developing of abscesses cannot be prevented.

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. 3.0 3.1 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. Frey C, Reber HA (1993). "Clinically based classification system for acute pancreatitis". Pancreas. 8 (6): 738–40. PMID 8255888.
  5. Robertson CH (1909). "ACUTE PANCREATITIS FOLLOWED BY PANCREATIC ABSCESS: OPERATION: RECOVERY". Br Med J. 1 (2508): 211–2. PMC 2317898. PMID 20764267.
  6. Ochsner AJ (1921). "DRAINAGE OF ABSCESS OF PANCREAS". Ann Surg. 74 (4): 434. PMC 1399727. PMID 17864533.
  7. Warshaw AL, O'Hara PJ (1978). "Susceptibility of the pancreas to ischemic injury in shock". Ann Surg. 188 (2): 197–201. PMC 1396740. PMID 686887.
  8. Frey CF, Lindenauer SM, Miller TA (1979). "Pancreatic abscess". Surg Gynecol Obstet. 149 (5): 722–6. PMID 505247.
  9. Warshaw AL (1974). "Inflammatory masses following acute pancreatitis. Phlegmon, pseudocyts, and abscess". Surg Clin North Am. 54 (3): 621–36. PMID 4597041.
  10. 10.0 10.1 10.2 10.3 10.4 Aranha GV, Prinz RA, Greenlee HB (1982). "Pancreatic abscess: an unresolved surgical problem". Am J Surg. 144 (5): 534–8. PMID 7137463.
  11. ALTEMEIER WA, ALEXANDER JW (1963). "Pancreatic abscess. A study of 32 cases". Arch Surg. 87: 80–9. PMID 14012297.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 16.0 16.1 16.2 16.3 Mithöfer K, Mueller PR, Warshaw AL (1997). "Interventional and surgical treatment of pancreatic abscess". World J Surg. 21 (2): 162–8. PMID 8995072.
  17. 17.0 17.1 Miller TA, Lindenauer SM, Frey CF, Stanley JC (1974). "Proceedings: Pancreatic abscess". Arch Surg. 108 (4): 545–51. PMID 4815930.
  18. Bradley EL, Fulenwider JT (1984). "Open treatment of pancreatic abscess". Surg Gynecol Obstet. 159 (6): 509–13. PMID 6438821.
  19. Johnson CD, Stephens DH, Sarr MG (1991). "CT of acute pancreatitis: correlation between lack of contrast enhancement and pancreatic necrosis". AJR Am J Roentgenol. 156 (1): 93–5. doi:10.2214/ajr.156.1.1898576. PMID 1898576.
  20. 20.0 20.1 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.
  21. Siegelman SS, Copeland BE, Saba GP, Cameron JL, Sanders RC, Zerhouni EA (1980). "CT of fluid collections associated with pancreatitis". AJR Am J Roentgenol. 134 (6): 1121–32. doi:10.2214/ajr.134.6.1121. PMID 6770619.
  22. Park JJ, Kim SS, Koo YS, Choi DJ, Park HC, Kim JH; et al. (2002). "Definitive treatment of pancreatic abscess by endoscopic transmural drainage". Gastrointest Endosc. 55 (2): 256–62. doi:10.1067/mge.2002.120887. PMID 11818936.