Although the latest recommendations on the management of severe acute pancreatitis advise against FNA because of the risk of infection of sterile necrosis. Current management is governed by stepwise treatment. In the situation described in the question the current treatment is to start antibiotics and assess response.

Patient with acute pancreatitis. Computerized Axial Tomography (CAT) performed 72 hours after admission showed necrosis of 50% of the pancreas. At the 3rd week of admission the patient began with high fever and leukocytosis. Urgent chest X-ray and urinary sediment are requested, both being normal. Indicate the next step to follow:

Fine needle aspiration of pancreatic necrosis guided by ultrasound or CT.

Bronchoalveolar aspirate, urine culture and blood cultures.

Echoendoscopy with puncture of the necrosis.

Acute pancreatitis

Computed tomography Regarding the need for computed tomography, practice guidelines state: CT is an important common initial assessment tool for acute pancreatitis. Imaging is indicated during the initial presentation if: the diagnosis of acute pancreatitis is uncertain there is abdominal distension and tenderness, fever >102 F (38,9 C), or leukocytosis there is a Ranson score > 3 or APACHE score > 8 there is no improvement after 72 hours of conservative medical therapy there has been an acute change in status: fever, pain, or shock CT is recommended as a delayed assessment tool in the following situations: acute change in status to determine therapeutic response after surgery or interventional radiologic procedure before discharge in patients with severe acute pancreatitis Abdominal CT should not be performed before the first 12 hours of onset of symptoms as early CT (<12 hours) may result in equivocal or normal findings.

Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis.

Early detection of infected pancreatic necrosis has a major impact on further management and outcome in acute pancreatitis. The aim of this study was to evaluate the clinical value of ultrasonographically guided fine-needle aspiration cytology (FNAC) in patients with necrotizing pancreatitis over an 8-year period. From January 1988 to September 1996 193 (mean 2.0 (range 1-9) aspirations per patient) prospectively assessed FNACs guided ultrasonographically were performed in 98 patients with necrotizing pancreatitis proven by contrast-enhanced computed tomography. Aspirates were considered infected if either Gram stain and/or culture revealed micro-organisms. Ultrasonographically guided FNAC correctly diagnosed infection in 29 of 33 patients with infected necrosis a median of 13 days after onset of symptoms. Of 61 patients with sterile necrosis 55 were identified correctly as sterile by FNAC. There were six false-positive and four false-negative aspirates of which nine occurred during the first week of the disease. In four patients who did not undergo operation FNAC revealed Gram-negative organisms; however, in the absence of repeated aspirations, the positive results remained unconfirmed. An overall sensitivity of 88 per cent and a specificity of 90 per cent was obtained. No difference was found in biochemical and clinical parameters indicating systemic inflammatory response syndrome before each FNAC between patients with proven sterile or infected necrosis. All patients tolerated the procedure well and no major complications were observed. Ultrasonographically guided FNAC is a fast and reliable technique for the diagnosis of infected necrosis. As complication rates are very low, the procedure can be repeated at short intervals to improve the diagnostic accuracy. Ultrasonographically guided FNAC is recommended for all patients with necrotizing pancreatitis in whom systemic inflammatory response syndrome persists beyond the first week after onset of symptoms.

[Technique and outcome of surgical therapy in acute pancreatitis].

The most important diagnostic step in the management of patients with acute pancreatitis is to discriminate between interstitial edematous and necrotizing pancreatitis. Measurement of necroses indicating parameters in the serum, like CRP and PMN-elastase are useful in detecting the necrotizing course of acute pancreatitis. While patients with acute edematous pancreatitis can be treated on a regular ward, patients with a necrotizing course of disease should be treated in the intensive-care unit. Patients with biliary acute pancreatitis should be examined by ERCP with the performance of a papillotomy with stone removal in case of impacted ampullary stones within 24 hours. Surgical decision-making in patients with necrotizing pancreatitis should be based on the development of septic signs due to infected pancreatic necrosis. The information about infected pancreatic necrosis can be easily obtained by a bedside ultrasound-guided fine needle aspiration and bacteriological examination of the aspirate [gram stain plus culture]. Patients without organ complications and with focal necroses should be treated conservatively while patients with persisting organ insufficiencies or progressive multiple organ failure despite maximum intensive care measures are candidates for surgical therapy. The procedure of choice in necrotizing pancreatitis is the careful removal of necrotic tissue [necrosectomy] followed and supplemented by a postoperative regimen for the continuous evacuation of further necrotic debris. For this postoperative therapeutical concept three comparable procedures are available today, the closed continuous lavage, the 'open packing technique' and the management by planned, staged re-laparotomies. Hospital mortality in severe acute pancreatitis has been reduced to less than 15% by these procedures in experienced hands.

[Acute pancreatitis: diagnosis].

In the differential diagnosis of abdominal pain, acute pancreatitis may be diagnosed by its clinical features together with blood determinations and ultrasonographic findings. The primary diagnostic steps include the differentiation between biliary or non-biliary etiology of the disease. In biliary acute pancreatitis, ERCP with endoscopic sphincterotomy is recommended, although the benefit of this procedure has only been shown in patients with severe clinical courses. An early discrimination between edematous-interstitial pancreatitis [mild clinical course] and necrotizing pancreatitis [severe clinical course associated with local and systemic complications] is possible by daily CRP-monitoring. In necrotizing pancreatitis, contrast-enhanced computed tomography is the next diagnostic step, and the patient should be transferred to an intensive care unit. To differentiate between severe sterile pancreatitis and infected pancreatic necrosis, ultrasonographic or CT-guided fine needle aspiration of the pancreatic inflammatory mass is suggested. Infected pancreatic necroses are associated with systemic septic complications, which are the main mortality factor and the major reason for operative treatment of necrotizing pancreatitis.

[Prognostic value of x-ray computed tomography in acute pancreatitis: contribution of the injection of intravenous contrast media].

Thirty seven patients suffering from acute pancreatitis were explored using contrast-enhanced computed tomography (CT). The authors found a good concordance between the extension of the lesions on the initial CT examination, prognostic criteria on admission and the course of the disease. In addition, a new prognostic CT sign was reported in the early phase of parenchymal contrast perfusion, i.e. the lack of contrast-enhancement in a limited portion of the pancreas. This sign was present in 8 patients, all with severe clinical symptoms. These 8 patients showed the highest morbidity rate in the series with abscess-type complications occurring in all, compared with 24 p. 100 among the 29 other patients who did not exhibit this CT sign. Moreover, these 8 patients showed the highest mortality rate (25 p. 100 compared with 3.5 p. 100 among the other patients). An histological analysis of partial pancreatectomy specimens was performed in 7 out of the 8 patients. Devitalized pancreatic tissue, at the site of the parenchymal abnormalities on CT scan, was found in all cases. One false negative case was reported. Contrast-enhanced CT scan seems to be the most reliable method for diagnosing pancreatic necrosis during acute severe pancreatitis. It appears to be an useful prognostic predictor of morbidity. It can improve the outcome of the disease by depicting and guiding needle aspiration of a fluid collection, and/or surgery in case of clinical findings suggesting abscess formation.

Acute pancreatitis

At admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11.1 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall >10% Oxygen (hypoxemia PO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis. Alternatively, pancreatitis can be diagnosed by meeting any of the following:[2] Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)

Acute pancreatitis

The risks of ERCP are that it may worsen pancreatitis, it may introduce an infection to otherwise sterile pancreatitis, and bleeding. Surgery Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii) complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria Gas bubbles on CT scan (present in 20 to 50% of infected necrosis) Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas. Surgical options for infected necrosis include: Minimally invasive management – necrosectomy through small incision in skin (left flank) or abdomen Conventional management – necrosectomy with simple drainage Closed management – necrosectomy with closed continuous postoperative lavage Open management – necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases)

Clinical, biochemical, and radiologic parameters at admission predicting formation of a pseudocyst in acute pancreatitis.

To evaluate clinical, biochemical, and radiologic parameters at admission, which predict the development of acute pseudocyst (AP) after acute pancreatitis. There is limited data on factors that predict the development of AP. Seventy-five consecutive patients with AP were prospectively enrolled and subjected to clinical, laboratory, and radiologic investigation. The patients were followed up for a period of 4 weeks and then investigated radiologically for the development of AP. After exclusion, 65 patients (44 males) were studied. The median age was 37 years (40.9±15.5 y). Etiology of acute pancreatitis was alcohol in 24 patients, gallstones in 18, both in 4, drugs in 4, pancreas divisum in 2, postendoscopic retrograde cholangiopancreatography in 1, trauma in 1, and idiopathic in 11 patients. On admission, acute fluid collections were observed in 34 (52.31%) patients. Necrosis was noted in 38 (58.46%) patients (<30% necrosis, 30% to 50% necrosis, and >50% necrosis was observed in 36.8%, 26.3%, and 36.8% patients, respectively). On follow-up, 34 (52.3%) patients developed a pseudocyst. On univariate analysis, the factors significantly associated with pseudocyst formation were male sex, palpable mass, blood sugar greater than 150 mg/dL, necrosis, sepsis, acute fluid collections, presence of ascites, pleural effusion, a high grade of pancreatitis, and a high computed tomography severity index (CTSI) score. Multivariate regression analysis showed that male sex, presence of a palpable abdominal mass, ascites, and a high CTSI score were associated with the development of AP. Male sex, palpable mass, ascites, and a high CTSI score at admission can predict the development of a pseudocyst after an attack of acute pancreatitis. Acute pancreatitis patients with these parameters at admission should be closely followed for the development of a pseudocyst.

Acute pancreatitis

Diagnosis Acute pancreatitis is diagnosed using clinical history and physical examination, based on the presence of at least 2 of 3 criteria: abdominal pain, elevated serum lipase or amylase, and abdominal imaging findings consistent with acute pancreatitis. Additional blood studies are used to identify organ failure, offer prognostic information, and determine if fluid resuscitation is adequate and whether ERCP is necessary. Blood investigations – complete blood count, kidney function tests, liver function, serum calcium, serum amylase and lipase Imaging – A triple phase abdominal CT and abdominal ultrasound are together considered the gold standard for the evaluation of acute pancreatitis. Other modalities including the abdominal x-ray lack sensitivity and are not recommended. An important caveat is that imaging during the first 12 hours may be falsely reassuring as the inflammatory and necrotic process usually requires 48 hours to fully manifest.

[CT guided percutaneous fine needle aspiration for early diagnosis of pancreatic infection after acute necrotizing pancreatitis].

To assess CT-guided percutaneous fine needle aspiration (FNA) for early diagnosis of pancreatic infection after acute necrotizing pancreatitis. CT-guided percutaneous FNA was employed to diagnose pancreatic infection after acute necrotizing pancreatitis in 14 patients. The aspirates were smeared, cultured and subjected polymerase to chain reaction (PCR) for detecting bacteria. Ten patients were diagnosed as having pancreatic infection and 4 non-pancreatic infection. FNA was totally performed for 15 times: left retroperitoneal route for 12 times, left and right retroperitoneal route for one time, and transperitoneal route for two times. The sensitivity of smear, PCR, culture to diagnose pancreatic infection was 7/10, 9/10, 10/10, respectively. Their specificity was 4/4, and the time for obtaining the results was 30 minutes, 4 hours, 3 days respectively. Retroperitoneal approach can be used for most patients with acute necrotizing pancreatitis when performing CT guided-percutaneous FNA. PCR of aspirates is a rapid and accurate method to diagnose pancreatic infection.

Pancreatic abscess

Some of the imaging tests are more commonly used to diagnose this condition. Abdominal CT scans, MRIs and ultrasounds are helpful in providing clear images of the inside of the abdomen and successfully used in the diagnosing process. These tests may reveal the presence of infected necrosis which has not yet developed into an abscess and as a result, doctors usually order repeated imaging tests in patients with acute pancreatitis whose abdominal pain worsens and who develop signs of abdominal obstruction. Also, it is recommended that patients who have a prolonged clinical response are tested repeatedly as a prevention method to avoid the development of an abscess that may rupture. Prevention In some cases, abscesses may be prevented by draining an existing pseudocyst which is likely to become inflamed. However, in most cases the developing of abscesses cannot be prevented.

InternalMed_Harrison

necrosis The management of necrosis requires a multidisciplinary team approach. Percutaneous aspiration of necrosis with Gram stain and culture should be performed if there are ongoing signs of possible pancreatic infection such as sustained leukocytosis, fever, or organ failure. There is currently no role for prophylactic antibiotics in necrotizing pancreatitis. It is reasonable to start broad-spectrum antibiotics in a patient who appears septic while awaiting the results of Gram stain and cultures. If cultures are negative, the antibiotics should be discontinued to minimize the risk of developing opportunistic or fungal superinfection. Repeated fine-needle aspiration and Gram stain with culture of pancreatic necrosis may be done every 5–7 days in the presence of persistent fever. Repeated CT or MRI imaging should also be considered with any change in clinical course to monitor for complications (e.g., thromboses, hemorrhage, abdominal compartment syndrome).

Pancreatic abscess

Pancreatic abscess is a late complication of acute necrotizing pancreatitis, occurring more than 4 weeks after the initial attack. A pancreatic abscess is a collection of pus resulting from tissue necrosis, liquefaction, and infection. It is estimated that approximately 3% of the patients suffering from acute pancreatitis will develop an abscess. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal pancreas, an enlargement that is focal or diffuse, mild peripancreatic inflammations or a single collection of fluid (pseudocyst) have less than 2% chances of developing an abscess. However, the probability of developing an abscess increases to nearly 60% in patients with more than two pseudocysts and gas within the pancreas. Signs and symptoms Patients with pancreatic abscesses may experience abdominal pain, chills and fever or the inability to eat. Whereas some patients present an abdominal mass, others do not. Nausea and vomiting may also occur.

[Severe acute pancreatitis. Clinical and therapeutic contribution of diagnostic imaging].

Ultrasonography and dynamic tomography are used in the study of acute pancreatitis, thus helping to interpret the diverse anatomophysiopathologic variables. We present 41 patients studied by ultrasonography, on admission and twenty-four hours later or more. After seventy-two hours, a dynamic tomography was performed. We did a clinicotomographic correlation assessing necrosis, and multiple Ranson criteria, being complemented with the anatomopathologic study of specimens both in the complications and in the elective biliary surgery. There were three puncture aspirates for bacteriology. Eight (19.5%) patients developed local complications and four (9.75%) presented organ failure. Ultrasonography showed biliopancreatic hypertension in 45% of cases of biliary pancreatitis and was reversible in nature. Dynamic tomography was important in defining morphology and pancreatic necrotic involvement. There were two patients with intrapancreatic necrosis, six with intra and extrapancreatic necrosis and eleven patients who presents a dissemination of the process into the extrapancreatic tissues. The prevalence of glandular necrosis was 24%. Both, ultrasonography and dynamic tomography allowed to the identify a spectrum of lesions representative of cavitated extrapancreatic necrosis and enzymatic pericholecystitis. Likewise, they contributed to define medical treatment as well as indications, opportunities and approaches in the surgical and/or percutaneous treatment of septic complications.

InternalMed_Harrison

An abdominal ultrasound is recommended in the emergency ward as the initial diagnostic imaging modality and is most useful to evaluate for gallstone disease and the pancreatic head. The revised Atlanta criteria have clearly outlined the morphologic features of acute pancreatitis on computed tomography (CT) scan as follows: (1) interstitial pancreatitis, (2) necrotizing pancreatitis, (3) acute pancreatic fluid collection, (4) pancreatic pseudocyst, (5) acute necrotic collection (ANC), and (6) walled-off pancreatic necrosis (WON) (Table 371-2 and Fig. 371-1). Radiologic studies useful in the diagnosis of acute pancreatitis are discussed in Chap. 370 and listed in Table 370-1.

Can early endoscopic ultrasound predict pancreatic necrosis in acute pancreatitis?

Presence of pancreatic/extrapancreatic necroses (PN/EPN) is an important prognostic indicator in acute pancreatitis (AP) and their early detection is a challenge. Endoscopic ultrasound (EUS) provides high resolution images of pancreas but there is paucity of data on its role in AP. Consecutive patients with AP seen at our center from December 2012-November 2013 and presenting within 5 days of onset of symptoms were prospectively enrolled. EUS was done on the day of admission with a radial echoendoscope and pancreatic/peripancreatic findings were compared with the abdominal computed tomography (CT) findings performed on day 7. Of the 46 patients evaluated, 14 were excluded, and 32 patients (22 male; age 40.68±12.46 years) underwent EUS at admission. The etiology of AP was alcohol in 16, gallstones in 13, and idiopathic in 3 patients. Necrotizing pancreatitis was present in 20 (62%) patients, and mean CT severity index was 6.45±2.96. In patients without PN (n=12), EUS revealed normal echo pattern in 6 patients and diffusely hyperechoic and enlarged pancreas in 6 patients. In patients with PN/EPN, EUS revealed multiple hypoechoic areas (>5 mm) in 5 patients, multiple hyperechoic areas (>5 mm) in 7 patients and mixed hypo and hyperechoic areas in 8 patients. Also, 13 of these patients had peripancreatic hypoechoic areas that correlated with EPN. Moreover, EUS detected common bile duct (CBD) stones in two patients, pleural effusion in 17 patients, and ascites in 15 patients. EUS done at admission can reliably detect PN and co-existent disorders like CBD stones.

Acute pancreatitis

The principal value of CT imaging to the treating clinician is the capacity to identify devitalised areas of the pancreas which have become necrotic due to ischaemia. Pancreatic necrosis can be reliably identified by intravenous contrast-enhanced CT imaging, and is of value if infection occurs and surgical or percutaneous debridement is indicated. Magnetic resonance imaging While computed tomography is considered the gold standard in diagnostic imaging for acute pancreatitis, magnetic resonance imaging (MRI) has become increasingly valuable as a tool for the visualization of the pancreas, particularly of pancreatic fluid collections and necrotized debris. Additional utility of MRI includes its indication for imaging of patients with an allergy to CT's contrast material, and an overall greater sensitivity to hemorrhage, vascular complications, pseudoaneurysms, and venous thrombosis.

Ranson Criteria -- Other Issues

It is important to understand that imaging is not indicated to assess a patient with mild acute pancreatitis unless the patient is suspected of having a malignancy. However, a CT scan of the abdomen is always indicated in patients with severe acute pancreatitis and is the imaging modality of choice in patients with complications. The CT scan is rarely needed within the first three days of admission unless the diagnosis is in doubt because most inflammatory alterations are often not visible on the scan at this time. Finally, in some patients with severe acute pancreatitis, image-guided aspiration may be required to differentiate sterile necrosis from a purulent infection.

Treatment of patients with severe acute necrotizing pancreatitis based on prospective evaluation.

To examine the impact of a prospectively applied diagnostic and treatment protocol in patients with severe acute necrotizing pancreatitis. During a 4-year period (1993-1996), 26 patients were treated for necrotizing pancreatitis, as documented by contrast-enhanced computed tomography (CE-CT). All patients were prospectively treated by medical means. Patients with persistent systemic inflammatory response syndrome underwent fine-needle aspiration for bacterial cultures. In case of positive results operative intervention was followed, while in negative results the conservative management was continued. Fine-needle aspiration was repeated every 5-7 days if systemic inflammatory response syndrome persisted or worsened. Sixty-five patients hospitalized during the preceding 11 years (1982-1992), when such a treatment was not constantly applied, served as controls. Infected pancreatic necrosis was demonstrated in 7 of the 26 patients (27%) and was treated by open drainage and/or post-operative lavage with a mortality rate of 14.2%. Thirteen patients in whom fine-needle aspiration was not necessary and 6 with negative cultures after fine-needle aspiration (73%) followed conservative treatment and the mortality rate was 5.2%. The total mortality rate of 7.7% was significantly lower than the mortality rate of 26.2% observed in the control group (p = 0.05). Recent evolution made in the management of severe necrotizing acute pancreatitis can lead to better results in the context of a strictly applied treatment protocol. Such protocols may improve mortality and serve as controls in future study.

Pancreatic pseudocyst after endoscopic ultrasound-guided fine needle aspiration of pancreatic mass.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is well known as a safe diagnostic procedure. We report the first case of pancreatic pseudocyst after EUS-FNA of the pancreatic body mass. A 60-year-old male underwent EUS-FNA for incidentally detected pancreatic solid mass which was suspected as neuroendocrine tumor. Two weeks later, the patient visited emergency room with acute abdominal pain and right upper quadrant tenderness; leukocytosis and elevated C-reactive protein, amylase, and lipase levels were noted. Computed tomography discovered newly developed 11.5×9.5 cm sized cystic mass communicating with the main pancreatic duct. Cyst fluid analysis revealed amylase level of 3,423 U/L and fluid culture isolated Streptococcus parasanguinis. The cystic mass corresponds with pancreatic pseudocyst. FNA induced main pancreatic duct injury and fluid leakage may cause it. Endoscopists who perform EUS-FNA must remember that pancreatic main duct injury can occur as one of severe complications and that it could be treated successfully with endoscopic internal drainage.

Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study.

<iBackground and Objectives</i: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. <iMaterials and Methods</i: A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (&lt;30%, 30-50%, &gt;50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. <iResults</i: The study included 83 patients (75.9% males (<in</i = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients (<in</i = 42, 51%). Positive blood culture (<in</i = 14 (87.5%)), multiple organ dysfunction syndrome (<in</i = 17 (73.9%)) and incidences of respiratory failure (<in</i = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% (<ip</i &lt; 0.05). Patients with &gt;50% of necrosis were significantly (<ip</i &lt; 0.05) more often diagnosed with moderately severe (<in</i = 24 (41.4%)) and severe (<in</i = 18 (72%)) AP. The number of surgical interventions (<in</i = 18 (72%)) and ultrasound-guided interventions (<in</i = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency (<in</i = 11 (64.7%)) and infected pancreatic necrosis (<in</i = 19 (57.6%)) was significantly higher (<ip</i &lt; 0.05). <iConclusions</i: The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment.

InternalMed_Harrison

FIGURE 371-1 Acute pancreatitis: computed tomography (CT) evolution. A. Contrast-enhanced CT scan of the abdomen performed on admission for a patient with clinical and biochemical parameters suggestive of acute pancreatitis. Note the abnormal enhancement of the pancreatic parenchyma (arrow) suggestive of interstitial pancreatitis. B. Contrast-enhanced CT scan of the abdomen performed on the same patient 6 days later for persistent fever and systemic inflammatory response syndrome. The pancreas now demonstrates significant areas of nonenhancement consistent with development of necrosis, particularly in the body and neck region (arrow). Note that an early CT scan obtained within the first 48 h of hospitalization may underestimate or miss necrosis. C. Contrast-enhanced CT scan of the abdomen performed on the same patient 2 months after the initial episode of acute pancreatitis. CT now demonstrates evidence of a fluid collection consistent with walled-off pancreatic necrosis (arrow).

Acute pancreatitis

Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT) Interpretation If the score ≥ 3, severe pancreatitis likely. If the score < 3, severe pancreatitis is unlikely Or Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality Score 5 to 6 : 40% mortality Score 7 to 8 : 100% mortality APACHE II score "Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality Hemorrhagic peritoneal fluid Obesity Indicators of organ failure Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min PO2 <60 mmHg Oliguria (<50 mL/h) or increasing BUN and creatinine Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>

Acute pancreatitis

Glasgow score The Glasgow score is valid for both gallstone and alcohol induced pancreatitis, whereas the Ranson score is only for alcohol induced pancreatitis. If a patient scores 3 or more it indicates severe pancreatitis and the patient should be considered for transfer to ITU. It is scored through the mnemonic, PANCREAS: P - PaO2 <8kPa A - Age >55-years-old N - Neutrophilia: WCC >15x10(9)/L C - Calcium <2 mmol/L R - Renal function: Urea >16 mmol/L E - Enzymes: LDH >600iu/L; AST >200iu/L A - Albumin <32g/L (serum) S - Sugar: blood glucose >10 mmol/L BISAP score Predicts mortality risk in pancreatitis with fewer variables than Ranson's criteria. Data should be taken from the first 24 hours of the patient's evaluation. BUN >25 mg/dL (8.9 mmol/L) Abnormal mental status with a Glasgow coma score <15 Evidence of SIRS (systemic inflammatory response syndrome) Patient age >60 years old Imaging study reveals pleural effusion

Acute pancreatitis

Balthazar score Developed in the early 1990s by Emil J. Balthazar et al., the Computed Tomography Severity Index (CTSI) is a grading system used to determine the severity of acute pancreatitis. The numerical CTSI has a maximum of ten points, and is the sum of the Balthazar grade points and pancreatic necrosis grade points: Balthazar grade Necrosis score CTSI's staging of acute pancreatitis severity has been shown by a number of studies to provide more accurate assessment than APACHE II, Ranson, and C-reactive protein (CRP) level. However, a few studies indicate that CTSI is not significantly associated with the prognosis of hospitalization in patients with pancreatic necrosis, nor is it an accurate predictor of AP severity. Glasgow score

Labeled granulocyte scanning for the diagnosis of infected necrosis in acute pancreatitis: what kind of labeling should be used?

Clinical and laboratory data or imaging results cannot provide a positive diagnosis of septic complications of pancreatic and peripancreatic necrosis in patients with acute pancreatitis. Confirmation can be obtained only after percutaneous computed tomography (CT)-guided aspiration of the necrotic tissues or fluid collection; although the important role of 99Tc(m)-HMPAO-labeled granulocyte scintigraphy has been recently emphasized. The aim of this study was to determine the sensitivity and specificity of 99m-technetium-hexamethylpropyleneamine oxime (99Tc(m)-HMPAO)- or 111In-oxine-labeled granulocyte scintigraphy for the diagnosis of infection in pancreatic or peripancreatic necrosis to define the ideal label for diagnosis. Thirty-six scintigraphic examinations were performed in 34 consecutive patients (mean age, 58 +/- 2 years) 20 +/- 2 days after the onset of acute pancreatitis (Balthazar classes A-C, n = 7; classes D and E, n = 29). The scintigraphic study included scintigraphic tomography and static acquisition 1 and 3 h, respectively, after reinjection of the autologous 99Tc(m)-labeled granulocytes and static images 3-4 and 24 h after the simultaneous reinjection of 111In-oxine-labeled autologous granulocytes. The diagnosis of infected pancreatic or peripancreatic necrosis was confirmed with percutaneous CT-guided aspiration (14 positive aspirates among 20 performed) and sterile necrosis after negative aspiration (6 negative aspirates) or after a 6 +/- 1-month follow-up free of clinical or biological signs of ongoing sepsis. The sensitivity and specificity were 86 and 73%, respectively, for scintigraphic tomography, 100 and 55% for 3-h 111In images, 93 and 68% for 3-4-h 111In images, and 100 and 64% for 24-h 111In images. The fall in splenic activity between the 3-4 and the 24-h 111In images was 26 +/- 3% in patients with septic pancreatic and peripancreatic necrosis (n = 14) and 16 +/- 3% in those with sterile necrosis (n = 22) (p < 0.01). Labeled granulocyte scintigraphy was thus shown to be an effective tool for the diagnosis of infection in pancreatic and/or peripancreatic necrosis due to acute pancreatitis, especially when the scintiscans are performed early after injection of 99Tc(m) or when the fall in splenic activity over the 24 h following reinjection of 111In is measured in particularly difficult cases. These promising preliminary results should be confirmed by a prospective study.

InternalMed_Harrison

Special Considerations Based on Etiology A careful history, review of medications, selected laboratory studies (liver profile, serum triglycerides, serum calcium), and an abdominal ultrasound are recommended in the emergency ward to assess for etiologies that may impact acute management. An abdominal ultrasound is the initial imaging modality of choice and will evaluate the gallbladder and common duct and assess the pancreatic head. Gallstone pancreatitis Patients with evidence of ascending cholangitis (rising white blood cell count, increasing liver enzymes) should undergo ERCP within 24–48 h of admission. Patients with gallstone pancreatitis are at increased risk of recurrence, and consideration should be given to performing a cholecystectomy during the same admission or within 4–6 weeks of discharge. An alternative for patients who are not surgical candidates would be to perform an endoscopic biliary sphincterotomy before discharge.

Correlation between admission laboratory values, early abdominal computed tomography, and severe complications of gallstone pancreatitis.

Our previous study demonstrated that Balthazar grade D or E pancreatitis on early abdominal computed tomography (CT) scan correlated with severe complications of gallstone pancreatitis (GP). To compare the efficacy of individual admission laboratory criteria, multiple criteria scoring systems and CT scan for predicting severe complications of GP. Consecutively admitted patients with GP underwent selective early CT scanning (<72 hours). All patients were prospectively monitored for severe complications. Of the 66 patients studied, 21 (32%) did not undergo for early CT scanning and underwent cholecystectomy with no complications. Forty-five patients (68%) had an early abdominal CT scan. Of the 12 patients with grade E pancreatitis, 6 (50%) developed severe complications versus only 2 of 33 (6%) with grade A to D pancreatitis (P = 0.002). A significant correlation was found between admission white blood cell count > or =14.5 x 10(9)/L and grade E pancreatitis on early CT scan (P = 0.002). However, admission glucose > or =150 mg/dL was the best predictor of complications (sensitivity 100%, negative predictive value 100%). Although Balthazar grade E on early CT scan correlates with severe complications of GP, admission glucose > or =150 mg/dL has a better sensitivity and negative predictive value, is quicker to use, and is more cost-effective as a prognostic indicator.

[Computer tomography and interventional radiologic methods in the diagnosis of acute pancreatitis].

The authors supervised the case record of 51 patients admitted between 1994 January and 1996 March suffering from acute pancreatitis. Diagnosis was made upon clinical signs, laboratory findings, abdominal ultrasound and CT examinations. In total 121 CT examinations were made mostly by using contrast material. Patients were classified with the help of Balthazar's grade. The authors emphasize that CT currently is the most accurate single imaging modality for diagnosis, staging the severity of the inflammatory process, and detecting complications of acute pancreatitis. They suggest that the first CT examination should be done within 3 days from the onset of the illness. In cases falling under group "C", "D" or "E" of Balthazar's grade, the CT examination should at least be repeated within 10 days. With 6 patients in septic state the bacteriological findings gained by fine needle aspiration was of great value for the further treatment.

Infected Pancreatic Necrosis Mimicking Pancreatic Cancer.

Although infected pancreatic necrosis can develop as a result of rare conditions involving trauma, surgery, and systemic infection with an uncommon pathogen, it usually occurs as a complication of pancreatitis. Early phase of acute pancreatitis can be either edematous interstitial pancreatitis or necrotizing pancreatitis. The late complications of pancreatitis can be divided into pancreatic pseudocyst due to edematous interstitial pancreatitis or walled-off necrosis due to necrotizing pancreatitis. During any time course of pancreatitis, bacteremia can provoke infection inside or outside the pancreas. The patients with infected pancreatic necrosis may have fever, chills, and abdominal pain as inflammatory symptoms. These specific clinical presentations can differentiate infected pancreatic necrosis from other pancreatic diseases. Herein, I report an atypical case of infected pancreatic necrosis in which abdominal pain, elevation of white blood cell, and fever were not found at the time of admission. Rather, a 10-kg weight loss (from 81 to 71 kg) over 2 months nearly led to a misdiagnosis of pancreatic cancer. The patient was finally diagnosed based on endoscopic ultrasound-guided fine-needle aspiration. This case highlights that awareness of the natural course of pancreatitis and infected pancreatic necrosis is important. In addition, endoscopic ultrasound-guided fine-needle aspiration should be recommended for the diagnosis and treatment of indeterminate pancreatic lesions in selected patients.

[Treatment of acute necrotizing pancreatitis].

Acute pancreatitis (AP) has an annual incidence of 30-45 per 100,000 inhabitants. In Germany approximately one third of the cases are of biliary or alcoholic origin. The diagnosis is based on the typical epigastric pain with radiation and a threefold increase of lipase or amylase in serum. Imaging procedures only rarely need to be included for the primary diagnostics. An early risk assessment is important to be able to allocate patients with severe AP to surveillance in an intensive care unit (ICU). Elevation of blood urea nitrogen, hematocrit and blood glucose are early predictors of poor outcome.The removal of impacted gall-stones by endoscopic retrograde cholangiography (ERC) is the only causal treatment of biliary AP, which must be carried out when there are signs of cholangitis and in severe biliary AP. Pain management and early fluid substitution are the most important symptomatic approaches. In the early phase of AP 150-250 ml/h of crystalloid solution should be administered to compensate for the extravasal loss of fluid. In certain cases, the initial fluid requirement might be even higher. In the ICU setting echocardiography and advanced hemodynamic monitoring are available for guidance. Prophylactic antibiotic treatment is not recommended in mild AP and it is a matter of debate even in severe AP. Early enteral nutrition has been shown to improve the outcome. Even in cases of fluid collection and necrosis a primary surgery approach should be avoided in favor of a "step-up" procedure with radiologically guided drainage as well as endoscopic and if necessary video-assisted percutaneous retroperitoneal débridement. Surgery remains an option for complications and for infected necrosis which cannot be reached by any other means.

[A CASE OF PULMONARY TUBERCULOSIS WITH PANCREATIC LESION].

A 52-year-old woman was referred to our hospital presenting with epigastric pain and weight loss. A contrast- enhanced abdominal computed tomography (CT) scan showed a low-density mass in the body of the pancreas, indicative of a malignancy. Endoscopic ultrasound-guided fine needle aspiration of the pancreatic mass was performed three times and showed no specific findings. A distal pancreatectomy was performed, and a pathological examination revealed epitheli- oid cell granulomas and necrosis. Ziehl-Neelsen staining did not reveal acid-fast bacilli in the pancreatic mass. A diagnosis of tuberculosis or sarcoidosis of the pancreas was con- sidered; however, the patient chose to undergo a follow-up examination without therapeutic intervention because the pancreatic mass had been removed completely and she had recovered well. Four months after the operation, the patient was readmitted to our hospital for insulin therapy for pancreatic diabetes. She presented with a fever and a productive cough, and a chest CT scan showed multiple nodules in both upper lobes. A bronchoscopy was performed and bronchoalveolar lavage fluid cultures for Mycobacterium tuberculosis were positive. The patient received antitubercular quadri-therapy and showed symptomatic and radiologic improvement. At the initial examination, we had been unable to establish the correct diagnosis; however, the detection of pulmonary lesions led to the time-delayed diagnosis of pancreatic tuber- culosis. Owing to its rarity, it is difficult to diagnose pancreatic tuberculosis using clinical symptoms and radiological imaging modalities; thus, pathologic and bacteriologic confirmation is essential. To avoid performing an unnecessary laparotomy in patients with pancreatic tuberculosis, increased vigilance and an accurate diagnostic approach are required.