Necrotizing pancreatitis
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At the time the article was created Yuranga Weerakkody had no recorded disclosures.
View Yuranga Weerakkody's current disclosuresAt the time the article was last revised Liz Silverstone had no financial relationships to ineligible companies to disclose.
View Liz Silverstone's current disclosures- Necrotising pancreatitis (NP)
- Necrotizing pancreatitis (NP)
- Necrotizing pancreatitis
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.
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Epidemiology
Around 5-10% of patients with interstitial edematous pancreatitis (i.e. uncomplicated acute pancreatitis) will develop necrosis 5.
Pathology
Necrotizing pancreatitis may become infected in up to 40% of cases 6, more commonly after the first week.
Radiographic features
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.
CT
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.
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.
Practical points
gas is the hallmark of infection
acute necrotic collection (<4 weeks): sterile or infected
walled-off necrosis (>4 weeks): sterile or infected
Quiz questions
References
- 1. Mortelé KJ, Girshman J, Szejnfeld D et-al. CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol. 2009;192 (1): 110-6. AJR Am J Roentgenol (full text) - doi:10.2214/AJR.08.1116 - Pubmed citation
- 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
- 6. Uhl W, Warshaw A, Imrie C et-al. IAP Guidelines for the Surgical Management of Acute Pancreatitis. (2002) Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]. 2 (6): 565-73. doi:10.1159/000071269 - Pubmed
- 7. Shyu J, Sainani N, Sahni V et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. Radiographics. 2014;34(5):1218-39. doi:10.1148/rg.345130012 - Pubmed
Incoming Links
- Pylephlebitis
- White line of Toldt
- Revised Atlanta classification of acute pancreatitis
- Emphysematous pancreatitis
- Splenic brucellosis
- Haemorrhagic pancreatitis
- Acute peripancreatic fluid collection
- Pancreatitis
- Splenic abscess
- Sinus tract
- Disconnected pancreatic duct syndrome
- Acute pancreatitis
- Medical abbreviations and acronyms (N)
- Portal venous varix
- Acute necrotic collection
- Pancreatic pseudocyst
- Walled-off pancreatic necrosis
- Necrotizing pancreatitis progressing to walled-off necrosis
- Necrotising pancreatitis
- Necrotising pancreatitis with hypoperfusion complex
- Necrotising pancreatitis with walled-off collections
- Necrotising pancreatitis
- Acute necrotizing pancreatitis with walled off necrotic collection (WON)
- Necrotizing pancreatitis
- Necrotizing pancreatitis
- Walled-off pancreatic necrosis
- Cystogastrostomy stent and pigtail catheter
- Necrotizing pancreatitis complicated by hemorrhage
- Journey through necrotizing pancreatitis - presentation, walled-off necrosis complicated by hemorrhage and infection, transgastric drainage, and resolution
- Journey through necrotising pancreatitis
- Acute peripancreatic collection
- Necrotising pancreatitis complicated by portal and splenic vein thrombosis
- Acute pancreatitis
- Necrotising pancreatitis with walled-off necrotic collection
- Haemorrhagic pancreatitis
- Necrotising emphysematous pancreatitis
- Necrotising pancreatitis
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