Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis, although it can occur in chronic pancreatitis or as a result of pancreatic trauma. Differentiation of WOPN from pancreatic pseudocyst is essential because management differs. WOPN may need aggressive treatment to avoid complications.
WOPN usually occurs four weeks after the episode of acute pancreatitis. Before this time, it is referred to as an acute necrotic collection (ANC).
The following are the latest terms according to the updated Atlanta classification to describe fluid collections associated with acute pancreatitis 10-11:
- fluid collections associated with interstitial oedematous pancreatitis (i.e. minimal or no necrosis)
- fluid collections associated with necrotising pancreatitis
The walled off collection may cause mass effect (e.g. against the biliary system, causing upstream dilatation). It may also become infected.
WOPN consists of necrosis and subsequent liquefaction of pancreatic and/or peripancreatic tissue. It may be intrapancreatic or parapancreatic.
A history of pancreatitis is necessary to exclude a complex cystic neoplasm. One should remember than an obstructing adenocarcinoma can cause pancreatitis, and if this is a concern, follow-up imaging (3-6 months) after the resolution of the pancreatitis would be useful to exclude a mass.
- cystic lesion within or around the pancreas with an area of heterogeneous attenuation nonenhancing (necrotic) tissue, surrounded by a wall 3
- remember to look for other sequelae of pancreatitis (e.g. pseudoaneurysm)
MRI is superior to CT in differentiating WOPN from pseudocyst, given its ability to depict the internal necrotic debris that favors the WOPN.
Treatment and prognosis
The mortality rate with WOPN is high but less than infected pancreatic necrosis (pancreatic abscess). Management depends on the patient's symptoms and the location of the WOPN. Since 40% of walled-off pancreatic fluid collections (including pseudocysts) resolve spontaneously 4, and ~10% of patients develop complications, conservative treatment may appropriate in some asymptomatic patients 5.
Symptomatic patients should have WOPNs drained. Percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography (ERCP) drainage (+/- necrosectomy) have been used to treat the walled off necrosis. These techniques are replacing surgical drainage 1,2.
Because the necrotic debris, WOPN usually requires a wide-bore drainage catheter as compared to the small caliber catheters that can be used to drain a pseudocyst 3.
History and etymology
The term "walled-off pancreatic necrosis" was used by Connor et al in 2005 2.
On imaging consider
- 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
- 1. Stamatakos M. World Journal of Gastroenterology. 2010;16 (14): . doi:10.3748/wjg.v16.i14.1707
- 2. Connor S, Raraty MG, Howes N et-al. Surgery in the treatment of acute pancreatitis-minimal access pancreatic necrosectomy. Scand J Surg. 2005;94 (2): 135-42. Pubmed citation
- 3. Takahashi N, Papachristou GI, Schmit GD et-al. CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy. Eur Radiol. 2008;18 (11): 2522-9. doi:10.1007/s00330-008-1039-1 - Pubmed citation
- 4. Cheruvu CV, Clarke MG, Prentice M et-al. Conservative treatment as an option in the management of pancreatic pseudocyst. Ann R Coll Surg Engl. 2004;85 (5): 313-6. doi:10.1308/003588403769162413 - Free text at pubmed - Pubmed citation
- 5. Yeo CJ, Bastidas JA, Lynch-Nyhan A et-al. The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet. 1990;170 (5): 411-7. Pubmed citation