Necrotising pancreatitis (NP) represents the severe form of pancreatitis. It is considered a subtype of acute pancreatitis as necrosis usually tends to occurs early, within the first 24-48 hours, but can also rarely occur with subacute forms.
A key feature is a significant amount of pancreatic and peripancreatic tissue necrosis associated with pancreatitis.
Around 5-10% of patients with interstitial oedematous pancreatitis (i.e. uncomplicated acute pancreatitis) will develop necrosis 5.
Necrotising pancreatitis can become infected, more commonly after the first week.
NP presents most often as necrosis affecting both the pancreas and peripancreatic tissues. Rarely it will affect only the peripancreatic tissues or pancreas in isolation 5.
Areas of necrosis are seen as non-enhancing low attenuating regions within the pancreas but observed if a dual phase pancreatic study is performed.
Foci of gas may also be present in more extreme cases; extraluminal gas is highly suggestive of superimposed infection.
Treatment and prognosis
The presence of necrosis implies a poorer prognosis with mortality rates reported up to 14% 3, if sterile. Mortality rates reach 20-30% in infected cases that are drained, either surgically or percutaneously, and about 100% in infected cases without drainage 5.
- gas is the hallmark of infection
- acute necrotic collection ( less than 4 weeks): sterile or infected
- walled-off necrosis (more than 4 weeks): sterile or infected
- cystic neoplasm (cystic pancreatic mass differential diagnosis)
- solid neoplasm
- nonepithelial pancreatic neoplasms
pancreatitis (mnemonic for the causes)
- gallstone pancreatitis
- interstitial oedematous pancreatitis
- necrotising pancreatitis
- haemorrhagic pancreatitis
- revised Atlanta classification of acute pancreatitis
- chronic pancreatitis
- Ascaris-induced pancreatitis
- tropical pancreatitis
- autoimmune pancreatitis
- emphysematous pancreatitis
- hereditary pancreatitis
- pancreatitis associated with cystic fibrosis
- segmental pancreatitis
- acute pancreatitis
- pancreatic atrophy
- pancreatic lipomatosis
- pancreatic trauma
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- 2. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13. Radiology (citation) - Pubmed citation
- 3. Ashley SW, Perez A, Pierce EA et-al. Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases. Ann. Surg. 2001;234 (4): 572-9. Ann. Surg. (link) - Free text at pubmed - Pubmed citation
- 4. Büchler MW, Gloor B, Müller CA et-al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann. Surg. 2000;232 (5): 619-26. Ann. Surg. (link) - Free text at pubmed - Pubmed citation
- 5. Baron TH, Morgan DE. Acute necrotizing pancreatitis. The New England journal of medicine. 340 (18): 1412-7. doi:10.1056/NEJM199905063401807 - Pubmed