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  • • Acute pancreatitis that clinically fails to improve, worsens or improves transiently followed by worsening of signs and symptoms

    • Fever

    • Leukocytosis

    • CT scan showing pancreatic necrosis and fluid collection; sometimes gas bubbles

    • Percutaneous aspiration of pancreatic fluid showing organisms on Gram stain and culture

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Epidemiology

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  • • Pancreatic abscess complicates about 5% of cases of acute pancreatitis and carries a high mortality

    • Develops in severe cases accompanied by hypovolemic shock and pancreatic necrosis and is an especially frequent complication of postoperative pancreatitis

    • Abscess formation follows secondary bacterial contamination of necrotic pancreatic debris and hemorrhagic exudates; the organisms may spread to the pancreas hematogenously as well as directly through the wall of the transverse colon

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Symptoms and Signs

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  • • Epigastric pain

    • Palpable tender mass

    • Fever

    • Jaundice (if biliary obstruction from inflammation)

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Laboratory Findings

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  • • Leukocytosis

    • Elevated bilirubin

    • Aspirated fluid collection

    • -Gram stain and culture demonstrating microbial organisms

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Imaging Findings

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  • Chest film: Pleural fluid and diaphragmatic paralysis

    CT scan: Fluid collection in the area of the pancreas; gas in the collection suggests infection

    • Percutaneous CT scan-guided aspiration: To obtain a specimen for Gram stain and culture

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  • • An abscess should be suspected when a patient with severe acute pancreatitis does not improve and rising fever develops or when symptoms return after a period of recovery

    • Distinguishing uninfected pancreatic necrosis from infected abscess can be difficult

    • -CT findings and aspiration of fluid collection may aid in making the diagnosis

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Rule Out

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  • • Uninfected pancreatic necrosis, which may not require surgical treatment

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  • • CBC

    • Abdominal CT scan with aspiration of fluid collection for Gram stain and culture

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When to Admit

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  • • All cases

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  • • Percutaneous drainage is inadequate

    • Surgical drainage and debridement of necrotic pancreatic debris and external drainage is required

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Surgery

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Indications

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  • • All cases of infected pancreatic abscess

    • An indication for operation in sterile pancreatic necrosis is controversial

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Medications

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  • • Broad-spectrum antibiotics

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Complications

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  • • Postoperative hemorrhage (immediate or delayed)

    • Pancreatic fistula

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Prognosis

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  • • Mortality rate is 20%, a consequence of the severity of the condition, incomplete surgical drainage, and delayed diagnosis

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Prevention

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  • • Controversial whether antibiotic administration in severe acute pancreatitis reduces risk of infected pancreatic abscess

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References

Baril NB et al. Does an infected peripancreatic fluid collection or abscess mandate operation? Ann Surg. 2000;231:361.  [PubMed: 10714629]
Beger HG, Rau B, Isenmann R: Prevention of severe change in acute pancreatitis: prediction and prevention. J Hepatobiliary ...

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