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Gastroenterology and Hepatology

Pancreatic Necrosis

Pancreatic necrosis is a serious infection usually associated with acute pancreatitis. During recurring attacks of pancreatitis, tissue within the pancreas may die (necrotize) and later become infected. This condition is called acute necrotizing pancreatitis. An abscess - also an infection - may form on the necrotic tissue several weeks after an attack of acute necrotizing pancreatitis. Both conditions are serious complications requiring multispecialty involvement, usually over a long hospital stay.

Over the past several years, Virginia Mason gastroenterologists designed and implemented a novel therapy combining endoscopic and percutaneous (through the skin) treatments that are significantly reducing patients' hospital time and recovery for these conditions. For more information or to schedule an appointment, call (206) 223-2319.

Symptoms of Pancreatic Necrosis

Symptoms of pancreatic necrosis or abscess may mimic those of acute or chronic pancreatitis, of which the most common is sudden pain in the upper abdomen. The pain is often worse when lying down but may feel less intense when sitting up or bending over.

Other symptoms include:

  • Nausea
  • Vomiting
  • Fever
  • Rapid pulse
  • Pain in the abdomen and back
  • Abdomen tender to the touch
  • Distended (bloated) abdomen

Serious complications
Both pancreatic necrosis and abscess are serious life-threatening infections of the pancreas usually associated with a blockage within the biliary tract, long-term alcohol use, or arising from an unknown cause. Patients who are not treated surgically to drain the pancreatic infection face systemic infection (sepsis) and, ultimately, death.

Diagnosing pancreatic necrosis or abscess

Your gastroenterologist may suspect acute pancreatic disease based on your medical history and your signs and symptoms. Tests and procedures to aid in the diagnosis include:

  • BLOOD TESTS
    Your blood may be tested for the presence of elevated white blood cells used by the body to fight infection, and for abnormal levels of pancreatic and liver enzymes.
     
  • ABDOMINAL ULTRASOUND
    This non-invasive procedure uses sound waves rather than x-rays to produce images. An ultrasound probe is passed over the abdomen and images are sent to a computer monitor.
     
  • ERCP WITH ENDOSCOPIC ULTRASOUND
    ERCP or endoscopic retrograde cholangiopancreatography is a specialized endoscopic technique used to study the ducts of the gallbladder, pancreas and liver. During an ERCP procedure, your gastroenterologist will pass a small flexible endoscope with a miniature TV camera inside through your mouth and into the stomach. After he or she sees the common opening to the ducts from the liver and pancreas, an ultrasound probe is passed through the ERCP that sends images to a computer monitor.
     
  • ABDOMINAL CT SCAN WITH IV CONTRAST A CT scan of the abdomen, after injection of a contrast dye, allows 3-dimensional images of the pancreas. Necrosis is suspected when the contrast agent is not "taken up" by the pancreatic tissue and thus is not viewable on a computer monitor.
     
  • MRI WITH CONTRAST
    MRI (magnetic resonance imaging) with injection of a special type of contrast material, called gadolinium, is increasing being used for diagnosing pancreatic necrosis or abscess. Necrosis is suspected when the contrast material is not "taken up" by the pancreatic tissue and thus is not viewable on a monitor.

Treating pancreatic necrosis or abscess

Patients with acute necrotizing pancreatitis or abscess receive antibiotics, intravenous fluids, pain relievers and other medications as indicated. Surgery in the operating room is the usual course of treatment to drain the infected area. Patients also may have a drain placed within the pancreas (called an indwelling drain) to aid in post-surgical removal of infected fluids.

Recognizing the high likelihood of medical complications, as well as patients' long-term hospital stay and recovery, Virginia Mason gastroenterologists designed and implemented a minimally invasive, "dual-modality drainage" technique for patients with acute necrotizing pancreatitis or abscess that allows for a shorter recovery and significantly reduced hospital time.

With this technique, a percutaneous (through the skin) drainage catheter is placed into the area of affected tissue by interventional radiology. Immediately following this procedure, the patient is transferred to the endoscopy suite where an endoscopic procedure is performed to place additional drains within the pancreas. The percutaneous drain is used as a flushing catheter allowing large pieces of devitalized (dead) tissue to drain while the endoscopically placed drains control the flow of pancreatic juice into the gastrointestinal tract in an attempt to avoid fistula (an abnormal opening) formation.

Over the ensuing weeks and months, patients continue treatment with antibiotics and have CT scans and "upsizing" of percutaneous drainage catheters. Treatment is continued until all fluid collections resolve. Once the CT scan has demonstrated resolution of the drainage, the percutaneous drain is removed. The pancreatic drains may stay in place for a longer period.

Over a two-year period, 13 patients received treatment with the "dual-modality drainage" technique and all had percutaneous drains successfully removed. None of the patients required open surgery and none developed fistulae.

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