Necrotizing pancreatitis

Last revised by Raymond Chieng on 26 Mar 2023

Necrotizing pancreatitis represents a severe form of acute pancreatitis. It is considered a subtype of acute pancreatitis as necrosis usually tends to occur 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 edematous pancreatitis (i.e. uncomplicated acute pancreatitis) will develop necrosis 5

Necrotizing pancreatitis may become infected in up to 40% of cases 6, more commonly after the first week. 

Necrotizing pancreatitis 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.

Dual phase CT abdomen-pelvis (pancreatic and portal venous phases) performed 3 to 5 days post symptom onset may show areas of necrotic changes. The necrotic areas are seen as non-enhancing or low attenuating regions (less than 30 HU) within the pancreas. CT performed before 3 days of symptom onset will be unable to rule out pancreatic necrosis 7.

After 4 weeks, pancreatic inflammations and collections generally will evolve into walled-off necrosis, presenting as heterogeneous or homogeneous collection with a well-defined wall 7.

In cases of known necrotizing pancreatitis, CT may be repeated if there is clinical deterioration, suspected complication, or as a baseline study before discharge or prior to a surgical intervention 7.

Foci of gas is highly suggestive of superimposed infection (see: emphysematous pancreatitis) 7

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.  

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Cases and figures

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  • Case 4
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  • Case 5
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  • Case 6: severe necrosis with infected collection
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  • Case 7: with emphysematous pancreatitis
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  • Case 8: associated with WON
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  • Case 9: acute peripancreatic collection
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  • Case 10
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  • Case 11: complicated by hemorrhage
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  • Case 16
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