Journey through necrotizing pancreatitis - presentation, walled-off necrosis complicated by hemorrhage and infection, transgastric drainage, and resolution

Case contributed by Dr Michael P Hartung

Presentation

Epigastric pain.

Patient Data

Age: 75 years
Gender: Male

Hypoenhancement of the pancreatic head through mid body (>50%). 

Acute necrotic collections and stranding about the pancreas. 

Patent vessels. 

More pronounced, striking hypoenhancement of the pancreatic head and body. 

Some sparing of the uncinate process, distal body, and tail. 

Acute necrotic collections and stranding. Ascites. Anasarca.

New nonocclusive thrombus in the splenic vein. 

RML segmental pulmonary embolus.

Walled-off necrosis (WON) has formed involving the hypoenhancing portions of the pancreatic head and body. WON also affects peripancreatic fat. 

New nonocclusive thrombus SMV. 

RLL pulmonary emboli.

Walled-off necrosis has enlarged and is now complicated by extensive hemorrhage, evident by T1 hyperintensity on pre-contrast images. 

Walled-off necrosis appears increasingly inflammatory, with mass effect and reactive inflammation involving the stomach and duodenum, with mucosal hyperenhancement and submucosal edema. 

Mass effect is obstructing the common bile duct. 

A small amount of pancreatic parenchyma near the tail has a dilated duct, which is presumably communicating with the walled-off necrosis.

Similar WON, inflammation, ascites compared to CT 3 days earlier.

Multiple areas of susceptibility (mottled dark signal) could represent air (suggesting infection) or non-liquified components with hemosiderin staining. It is hard to be certain and could be distinguished with repeat non-contrast CT. 

Percutaneous transgastric 14 French drain was placed into the WON using fluoroscopy. Contrast injection through the tube (abscessogram) confirms positioning, and shows the extent and branching communication of main collection with smaller peripheral collections.

Percutaneous transgastric drain with decreasing WON. Small remaining collections. Improving biliary ductal dilation.  Similar spared pancreatic parenchyma in the uncinate process and tail. Improving inflammation of the stomach and duodenum. Mild reactive adenopathy. 

Transgastric drain has been converted to a gastrostomy tube. Only a small collection (WON) remains in the right mid abdominal mesentery. The pancreatic/peripancreatic collections appears mostly resolved with only soft tissue thickening remaining, presumably the fibrous capsule of drained WON. 

Amazingly, 2 years after presentation, the collections have completely resolved. The spared pancreatic parenchyma has mild residual ductal dilation but has found a way to communicate with the major duodenal papilla. 

Patient also underwent elective cholecystectomy in the interval with temporary placement of plastic biliary stent due to stricture from prior inflammation. 

Case Discussion

This case is a long and complex journey, and I hope by the end you feel as relieved for the patient as I do! 

Sequence of events with key comments:

  1. Day 1-3: necrotizing pancreatitis involving > 50%, which become strikingly more apparent on day 3
  2. Day 30: formation of walled off necrosis 
  3. Day 35: hemorrhage, resulting in enlarging collections
  4. Day 90-93: enlarging WON with increasing inflammation and possible air on MRI, concerning for infection. 
  5. Day 95-100: percutaneous transgastric drainage of WON. This is a fascinating technique that was extremely effective. Why it works: (a) any leakage of the cyst contents around the drain goes right into the stomach, and (b) following drain removal, if there is persistent communication of the drained collection with the pancreatic duct (as was likely by the pancreatic tail), it has a fistulous tract into the stomach mimicking a surgical cystogastrostomy, preventing the formation of a pancreaticocutaneous fistula1. Perhaps surprisingly, the patients can eat with this in place! 
  6. Day 125: temporary conversion of the drain into a gastrostomy tube, in order to allow the gastrostomy tract to mature prior to tube removal. 
  7. 2 years later: Complete resolution! 
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Case information

rID: 67125
Published: 24th Mar 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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