Necrotizing pancreatitis... another case... - Forum

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Jorjo

Necrotizing pancreatitis... another case... - Ärzteforum

Post#1 »

Another case has been followed by us. 53 yo male, diabetes non
insulinodependent. Had Glybenclamide 5 mgrs. twice a day. Not well
compensated, glycemia over 200,presents with a severe pain in his upper
abdomen, fever, jaundice,high levels of amylase and lypase. .WBCC over
46 K.,USN reveals a gallbladder full of stones,CBD dilated to 8 mms.ERCP
+ ES performed,permits drainage of purulent content and extraction of
stones (2). AB coverage with cephoperazone + Flagyl. Diabetes needs
control with Cristaline Insulin administered by infussion pump (90 units
per day). TPN at the beginning,then intestinal feeding through a
nasoyeyunal tube.

The patient hasn't improved much.Very difficult management of his
diabetes. A CT scan showed an acute pancreatitis type D Ranson
Balthazar. Huge enlargement of the gland with a collection near the
tail of about 8 x 6 x 4 cms. Inhomogenous contents. The patient
continued to look septic and a percutaneous drainage under CT scan
control was performed last Wednesday. 30 cc of pus was collected and a
tube left in place. Interventional radiologists continue daily control
of the collection, washing the cavity with saline. I'll see him again
tomorrow.

Questions .

1.- Do you think percutaneous drainage will be enough?

2.- Do you believe that surgery should be kept in mind to be done soon?

3.- All other routine measures are being done in the management of his
pancreatitis.Do you suggest something special?

4.- I want to remind you that 5 similar cases we've had in the last
months have been treated with percutaneous drainage,up to 3 catheters
left in place, and results have been excellent with total recovery of
the patients.


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Surgeon

Re: Necrotizing pancreatitis... another case... - Ärzteforum

Post#2 »

Questions .

>1.- Do you think percutaneous drainage will be enough?

My honorable colleague knows surely the importance to distinguish between
"pancreatic abscess" or "peripancreatic abscess" -which may respond to PC
drainage- and "infected necrosis" (IPN) which - a consensus opinion
suggests- mandates an operation.

I would like to know how the pus looked? Was it yellow (i.e. an abscess)
or beer- dark black (i.e. Irish beer)? The latter suggests IPN.

My honorable friend also knows that it is very uncommon to develop IPN or
an abscess during the first 10 days of the disease. During days 10-30 IPN
is the common infected complications and later on- abscesses are developing
as a residual process.

It is strange, therefore, that your patient has a solitary abscess so early
in his illness. I wish to know therefore what was the bacteriology of the
"abscess'- if negative, I suggest with respect that we are dealing with a
sterile acute peri-pancreatic collection which due to high fibrin content
looks like an abscess but is not!


> .- Do you believe that surgery should be kept in mind to be done soon?

My suggestions:

1. Dark "pus' containg bacteria- operate for IPN.

2. Dark "pus"-sterile - wait; re-aspirate and re-culture; operate if no
clinical improvememt,

3. Yellow pus with bacteria- operate if PC drainage fails.

4. Yellow "pus" without bacteria- you are dealing with sterile
peri-pancreatic collection- wait,

According to my understanding of the natural history of the process - you
are dealing with situation number 4 as I have never seen situation number 3
during the early stages of acute pancreatitis.


> 4.- I want to remind you that 5 similar cases we've had in the last
months have been treated with percutaneous > drainage,up to 3 catheters
left in place, and results have been excellent with total recovery of the
patients...

Again, let me re-emphasize that in reporting such patients it is crucial to
adhere to the well established Atlanta classification of complicated acute
pancreatitis.

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