Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Pancreas
Question 4#

A 35-year-old male is hospitalized following a first episode of acute severe gallstone pancreatitis. Initially, he presented to the emergency department with tachycardia, hypotension, and signs of end organ dysfunction. After aggressive resuscitation and supportive management in the ICU he showed signs of improvement. On hospital day 18 he develops new fevers and an associated leukocytosis. A computed tomography (CT) abdomen/pelvis is obtained that showed new air in areas of previously noted pancreatic necrosis.

Which of the following statements is true regarding this patient’s condition?

A. Use of prophylactic antibiotics has been shown to decrease the rate of infection in necrotizing pancreatitis
B. Primary management is urgent surgical debridement to attain source control
C. Mortality associated with infected pancreatic necrosis ranges from 70% to 80%
D. Current management involves initiation of antibiotic therapy and a step-up approach utilizing minimally invasive and endoscopic techniques
E. Diagnostic Fine Needle Aspiration is required for a diagnosis of infected pancreatic necrosis

Correct Answer is D

Comment:

Correct Answer: D

Acute pancreatitis is an acute inflammatory reaction caused by a variety of etiologies. A subset of patients with acute pancreatitis develops necrosis of a portion of the pancreatic parenchyma and surrounding tissues, which is termed necrotizing pancreatitis. In the acute setting, these necrotic collections are comprised of fluid and necrotic tissue, which over time organize into walled off pancreatic necrosis. Initially presumed sterile, 15% to 30% of collections eventually become infected, which is manifested by clinical deterioration, usually several weeks after an episode of acute pancreatitis. This patient likely has infected pancreatic necrosis. CT imaging demonstrates the presence of gas or air within the collections. Gas within necrosis is due either due to the presence of gas-forming microorganisms or fistulization into the gastrointestinal tract. This is diagnostic of infection and Fine Needle Aspiration is not required for the diagnosis of infected pancreatic necrosis. The first step in management is initiation of intravenous antibiotic therapy. In patients who fail to respond to IV antibiotic therapy alone, a step-up approach is used, which involves percutaneous or endoscopic drainage followed by minimally invasive or endoscopic necrosectomy. With the widespread utilization of minimally invasive approaches rather than traditional open necrosectomy, mortality associated with infected necrotizing pancreatitis has significantly decreased from 40%-60% to 10%-20%. Prophylactic use of antibiotics has not been shown to prevent superinfection of initially sterile pancreatic necrosis and thus is not recommended.

References:

1. Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101(10):2379-2400.
2. Beger HG, Rau BM. Severe acute pancreatitis: clinical course and management. World J Gastroenterol. 2007;13(38):5043-5051.
3. van Santvoort HC, Besselink MG, Bakkar OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491-1502.