Sandbox:pancreatic abscess: Difference between revisions

Jump to navigation Jump to search
 
(34 intermediate revisions by the same user not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
==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> It 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 pancreatic and peri-pancreatic tissues, but some arise from infection of peripancreatic fluid or collections elsewhere in the peritoneal cavity. It 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>
==Historical Perspective==
==Historical Perspective==
==Pathophysiology==
==Causes==
==Causes==
===Common Causes===
===Common Causes===
Line 20: Line 25:


==Differentiating Pancreatic Abscess from other Diseases==
==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.<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>
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.<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>
* Recurrent pancreatitis
* Recurrent pancreatitis
'''Pancreatic necrosis'''
'''Pancreatic necrosis'''
Line 36: Line 41:
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Definition'''}}
|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 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 peripancreatic tissue, but without any significant pus collections
|Necrotic pancreas defined as a diffuse bacterial inflammation of necrotic pancreatic and peripancreatic tissue, but without any significant pus collections
|
|
Line 42: Line 47:
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Presentation'''}}
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Presentation'''}}
|Present after onset of symptoms and after subsidence of the acute phase of pancreatitls
|Present after onset of symptoms and after subsidence of the acute phase of pancreatitls
|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 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.
|
|-
|colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Laboratory Findings'''}}
|
* Hyperamylasemia
* Hypocalcemia <8 mg/dl
* Blood glucose >200 mg/dl
* LDH >350 units/liter
|
|
|
|clinically evident during the early phase of acute pancreatitis with signs of sepsis
* LDH >350 units/liter
* Hypocalcemia <8 mg/dl
* Blood glucose >200 mg/dl
|
|
|-
|-
Line 75: Line 99:
==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
===Complications===
===Complications===
* Intra abdominal sepsis
{| border="1"
* Peritonitis  
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Common complications}}
* Septicemia
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Respiratory complications}}
* Renal failure
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Gastric complications}}
* Pleural effusion
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Colon complications}}
* Bronchopneumonia  
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Other complications}}
* Atelectasis
|-
* Pulmonary embolus
|valign=top|
* Hepatic failure
* [[Sepsis|Intra abdominal sepsis]]
'''Gastric complications'''
* [[Peritonitis]]
* GI bleeding
* [[Septicemia]]
* Gastric outlet obstruction
* [[Pancreatic fistula]]
'''Colon complications'''
|valign=top|
'''Other complications'''
* [[Pleural effusion]]
* Pancreatic fistula
* [[Bronchopneumonia]]
* Pancreaticocolocutaneous fistula
* [[Atelectasis]]
* [[Pulmonary embolus]]
|valign=top|
* [[Gastrointestinal bleeding|GI bleeding]]
* [[Gastric outlet obstruction]]
|valign=top|
* [[Fistula|Colonic fistula]]
|valign=top|
* [[Fistula|Pancreaticocolocutaneous fistula]]
* Wound infection
* Wound infection
* Recurrent abdominal pain
* [[Fistula|Duodenal fistula]]
* Duodenal fistula
* [[Renal failure]]
* [[Hepatic failure]]
|}
 
===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>\
 
'''Poor prognostic factors'''
* Delayed diagnosis


==Association==
==Association==
* Biliary tract disease
* [[Biliary tract diseases resident survival guide|Biliary tract disease]]
* Alcohol addiction
* [[Alcohol, Drug Abuse, and Mental Health Services Block Grant|Alcohol addiction]]
* Carcinoma
* [[Carcinoma]]
* Peptic ulcer
* [[Peptic ulcer]]
* Trauma
* [[Trauma]]
* Polyarteritis nodosa
* [[Polyarteritis nodosa]]
==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.
===History and Symptoms===
===History and Symptoms===
====Common Symptoms====
====Common Symptoms====
Line 121: Line 162:
===Physical Examination Findings===
===Physical Examination Findings===
* 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>
* Abdominal mass
* Palpable abdominal mass
* Abdominal distention  
* Abdominal distention  
===Lab Findings===
===Lab Findings===
* Leukocytosis (range between 10,500 to 35,00O/mm<sup>3</sup>)
====Blood Tests====
* '''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>
 
===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>
====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>
Line 132: Line 177:
* Diaphragmatic elevation
* Diaphragmatic elevation
* Basilar atelectasis
* Basilar atelectasis
====Ultrasound====
====Ultrasound====
* Shows fluid filled sac suggesting abscess
* Shows fluid filled sac suggesting abscess
====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>
===Fine Needle Aspiration===
'''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>
* High sensitivity of 90% to 100%
* Low complication rate
* It aid in the early diagnosis of infectious complications of pancreatic abscess and to avoid unnecessary laparotomy.


== Treatment ==
== Treatment ==


=== Surgical Therapy ===
=== Surgical Therapy ===
Surgical therapy is the traditional method of treatment of pancreatic abscesses, usually by inserting one or more non-traumatic drains through transperitoneal or throguh flank or retroperitoneum into the abscess cavity. Failure of the surgical drainage might be due to the reluctance to expose the cavity widely and to debride the necrotic components aggressively.
===Transpapillary Drainage===
===Transpapillary Drainage===



Latest revision as of 17:39, 14 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] 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. It 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

Pathophysiology

Causes

Common Causes

Common organisms causing pancreatic abscess are as follows:[5]

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.[6][7][8]

  • 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. 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 peripancreatic tissue, but without any significant pus collections
Presentation Present after onset of symptoms and after subsidence of the acute phase of pancreatitls 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
  • Hyperamylasemia
  • Hypocalcemia <8 mg/dl
  • Blood glucose >200 mg/dl
  • LDH >350 units/liter
  • LDH >350 units/liter
  • Hypocalcemia <8 mg/dl
  • Blood glucose >200 mg/dl
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.[9]

Case Fatality Rate

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

Age

Gender

Race

Developed Countries

Developing Countries

Risk Factors

  • History of alcoholic pancreatitis who fails to respond to medical therapy[5][11]

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%.[12]\

Poor prognostic factors

  • Delayed diagnosis

Association

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.

History and Symptoms

Common Symptoms

Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:[5]

Less common symptoms

Vital signs

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

Physical Examination Findings

  • Abdominal tenderness[5]
  • Palpable abdominal mass
  • Abdominal distention

Lab Findings

Blood Tests

  • CBC with differential: Leukocytosis (range between 10,500 to 35,00O/mm3)
  • 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.[13]

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][14]

X-ray

  • Shows extraluminal (pancreas or lesser sac) gas bubbles suggesting abscess[11]
  • Disclosed pleural effusion[15]
  • Diaphragmatic elevation
  • Basilar atelectasis

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.[13]

Fine Needle Aspiration

Advantages

  • Fine needle aspiration can distinguish sterile inflammation from infection and it is the procedure of choice in the verification of bacterial infection.[13]
  • High sensitivity of 90% to 100%
  • Low complication rate
  • It aid in the early diagnosis of infectious complications of pancreatic abscess and to avoid unnecessary laparotomy.

Treatment

Surgical Therapy

Surgical therapy is the traditional method of treatment of pancreatic abscesses, usually by inserting one or more non-traumatic drains through transperitoneal or throguh flank or retroperitoneum into the abscess cavity. Failure of the surgical drainage might be due to the reluctance to expose the cavity widely and to debride the necrotic components aggressively.

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. 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. 5.0 5.1 5.2 5.3 Aranha GV, Prinz RA, Greenlee HB (1982). "Pancreatic abscess: an unresolved surgical problem". Am J Surg. 144 (5): 534–8. PMID 7137463.
  6. ALTEMEIER WA, ALEXANDER JW (1963). "Pancreatic abscess. A study of 32 cases". Arch Surg. 87: 80–9. PMID 14012297.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 11.0 11.1 Miller TA, Lindenauer SM, Frey CF, Stanley JC (1974). "Proceedings: Pancreatic abscess". Arch Surg. 108 (4): 545–51. PMID 4815930.
  12. Bradley EL, Fulenwider JT (1984). "Open treatment of pancreatic abscess". Surg Gynecol Obstet. 159 (6): 509–13. PMID 6438821.
  13. 13.0 13.1 13.2 Mithöfer K, Mueller PR, Warshaw AL (1997). "Interventional and surgical treatment of pancreatic abscess". World J Surg. 21 (2): 162–8. PMID 8995072.
  14. 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.
  15. 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.

Template:WH Template:WS