Pancreatic Abscess

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • Epigastric pain

  • Palpable tender mass

  • Fever

  • Jaundice (if biliary obstruction from inflammation)

Laboratory Findings

• • Leukocytosis

  • Elevated bilirubin

  • Aspirated fluid collection

  • -Gram stain and culture demonstrating microbial organisms

Imaging Findings

• • 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

• • 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

Rule Out

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

• • CBC

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

When to Admit

• • All cases

• • Percutaneous drainage is inadequate

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

Surgery

Indications

• • All cases of infected pancreatic abscess

  • An indication for operation in sterile pancreatic necrosis is controversial

Medications

• • Broad-spectrum antibiotics

Complications

• • Postoperative hemorrhage (immediate or delayed)

  • Pancreatic fistula

Prognosis

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

Prevention

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

References