Pancreatic abscess

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Synonyms and Keywords:  Abscess of pancreas
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Overview

Pancreatic abscess is an unusual and rare, but life threatening complication of acute pancreatitis. It develop 5 weeks after the onset of pancreatitis and after onset of symptoms and subsidence of the acute phase of pancreatitis.[1] Most of the pancreatic abscesses are developed from the progressive liquefaction of necrotic pancreatic and peri-pancreatic tissues, but some arise from infection of peri-pancreatic fluid or collections elsewhere in the peritoneal cavity. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal pancreas, an enlargement that is focal or diffuse, mild peri-pancreatic 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. Pancreatic abscess is the most dangerous complication and the most common cause of death for acute pancreatitis.[2][3]

Definition

Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas.[4]

Historical Perspective

  • First case of pancreatic abscess is described by Carrick H. Robertson in 1908.[5]
  • Simple and safe method of surgical draining for pancreatic abscess described by Albert J. Ochsner in 1921.[6]

Pathophysiology

Pathogenesis of pancreatic abscesses is due to combination of ischemic necrosis and enzymatic injury to the pancreatic tissue by escaped pancreatic enzymes.[7] Pancreatic abscess is commonly present in 1% to 30% of all patients with clinical acute pancreatitis, but it is more frequetly occurs in up to 50% to 70% of patients with severe necrotizing pancreatitis.[8][9]

Acute pancreatitis

Necrotizing pancreatitis resulting due to more severe tissue destruction

Increase in intestinal permeability to bacteria

Increased rate of infection of the necrotic tissue

Abscess formation

Causes

Common Causes

Common organisms causing pancreatic abscess are as follows:[10]

Aerobic bacteria Anaerobes bacteria Fungal Parasite

Differentiating Pancreatic Abscess from other Diseases

Pancreatic abscess should be diagnosed early and treat promptly not only to reduce morbidity and mortality, but also it is important to differentiate from other pancreatic diseases such as: recurrent pancreatitis and pancreatic pseudocysts as the undrained abscess carreies high risk of mortality.[11][12][13]

Characteristics Pancreatic abscess Infected pancreatic pseudocyst Infected necrotic pancreas
Definition Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas. Pancreatic pseudocyst is defined as a collection of pancreatic juice enclosed by a non-epithelialized wall, that developed as a complication of acute pancreatitis, pancreatic trauma, or chronic pancreatitis. Necrotic pancreas defined as a diffuse bacterial inflammation of necrotic pancreatic and peri-pancreatic tissue but without any significant pus collections
Presentation Present after onset of symptoms and after subsidence of the acute phase of pancreatitis Present after 5 weeks of acute pancreatitis clinically evident during the early phase of acute pancreatitis with signs of sepsis
Pathology Pancreatic abscess contains pus with viable bacteria or fungi and little or no pancreatic necrosis. This pathology differentiates abscess from infected necrosis. Presence of well-defined wall composed of granulation or fibrous tissue that distinguishes a pseudocyst from an acute fluid collection (cyst). The fluid is usually rich in pancreatic enzymes and is most often sterile. Pathology shows areas of devitalized pancreatic parenchyma and peri-pancreatic fat necrosis.
Laboratory Findings
  • Serum findings have limited use
  • Mild increase in amylase, lipase levels but with in the reference range
  • Mild elevation in LFT.
CT Findings Absent or limited necrosis with pus Pancreatic pseudocyst with a well defined rounded cystic lesion is seen Well marginated zones of non-enhanced pancreatic parenchyma
Prognosis Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59% Mortality is high compared to pancreatic abscess

Epidemiology and Demographics

Incidence

Incidence of pancreatic abscess is unknown, but McClave et al reported it as 2-5% among patients hospitalized for pancreatitis.[14]

Case Fatality Rate

Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59%.[15]

Age & Gender

No age and gender predilection for pancreatic abscess.

Race

Pancreatic abscess has no race predilection.

Risk Factors

Pancreatic abscess often co-exists with several risk factors, but the major one is the acute pancreatitis.[16] Common risk factors of pancreatic abscess include:[10][17]

Common risk factors Less common risk factors

Natural History, Complications and Prognosis

Complications

Common complications Respiratory complications Gastric complications Colon complications Other complications

Prognosis

Prognosis of pancreatic abscess depends on the time of diagnosis and treatment. Outcome of pancreatic abscess is generally based on the severity of the infection. It is however a severe complication which may result in the death of the patient if the appropriate treatment is not administered. Patients are at risk of sepsis and multiple organ failure and in patients with delay in surgery to remove infected abscess, the mortality rate can get to 100%.[18]

Poor prognostic factors

Diagnosis

As the clinical presentation of pancreatic abscess is variable or even obscure, it should be considered in any febrile patient even 2 weeks after an attack of acute pancreatitis, even in the absence of other symptoms. Most patients who develop pancreatic abscesses have had pancreatitis, so a complete medical history is required as a first step in diagnosing abscesses.

History and Symptoms

Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:[10]

Common Symptoms Less Common Symptoms

Physical Examination Findings

Appearance

Patient with pancreatic abscess appears ill and diaphoretic

Vital signs

If patient present with sepsis:

Heart

  • No specific cardiovascular findings related to pancreatic abscess.

Lungs

Left sided pleural effusion may be present with signs of:

Abdomen

Palpation

Lab Findings

Blood Tests

Fine Needle Aspiration

Advantages

Imaging

Imaging studies are crucial in the diagnosis and treatment of pancreatic abscess. Both ultrasonography and computed tomography (CT) can be helpful with the diagnosis and localization of pancreatic abscesses, which may extend from the pancreas anywhere (e.g. retroperitoneum, mesentery, mediastinum, and even the neck or genitalia).[3][19]

X-ray

Ultrasound

  • Shows fluid filled sac suggesting abscess

CT

CT had a sensitivity of 74%, compared with 35% for ultrasound in the diagnosis of pancreatic abscess.[16]

CT of Pancreatic abscess

Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 20938

CT of Pancreatic psuedocyst

Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 25280

Treatment

Medical Therapy

Antibiotics are commonly used as a curing method for pancreatic abscesses although their role remains controversial. Prophylactic antibiotics are normally chosen based on the type of flora and the degree of antibiotic penetration into the abscess.[20] Pancreatic abscesses are more likely to host enteric organisms and pathogens such as E. coli, Klebsiella pneumonia, Enterococcus faecalis, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, and Streptococcus species. Medical therapy is usually given to people whose general health status does not allow surgery. On the other hand, antibiotics are not recommended in patients with pancreatitis, unless the presence of an infected abscess has been proved.

Surgical Therapy

Surgical therapy is the traditional method of treatment of pancreatic abscesses, usually by inserting one or more non-traumatic drains through trans-peritoneal or through flank or retroperitoneum into the abscess cavity. Although there have been reported cases of patients who were given medical treatment and survived, primary drainage of the abscess is the main treatment used to cure this condition. Drainage usually involves a surgical procedure. It has been shown that CT-guided drainage brought inferior results than open drainage.[21] Hence, open surgical procedure is preferred to successfully remove the abscess. However, CT-guided drainage is the option treatment for patients who may not tolerate an open procedure. Endoscopic treatment is at the same time a treatment option that increased in popularity over the last years. Failure of the surgical drainage might be due to the reluctance to expose the cavity widely and to debride the necrotic components aggressively.[22][10] For a detailed approach on performing surgical drainage of pancreatic abscess watch the video below:

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.

References

  1. Bittner R, Block S, Büchler M, Beger HG (1987). "Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis". Dig Dis Sci. 32 (10): 1082–7. PMID 3308374.
  2. Bolooki H, Jaffe B, Gliedman ML (1968). "Pancreatic abscesses and lesser omental sac collections". Surg Gynecol Obstet. 126 (6): 1301–8. PMID 5652669.
  3. 3.0 3.1 Ranson JH, Balthazar E, Caccavale R, Cooper M (1985). "Computed tomography and the prediction of pancreatic abscess in acute pancreatitis". Ann Surg. 201 (5): 656–65. PMC 1250783. PMID 3994437.
  4. Frey C, Reber HA (1993). "Clinically based classification system for acute pancreatitis". Pancreas. 8 (6): 738–40. PMID 8255888.
  5. Robertson CH (1909). "ACUTE PANCREATITIS FOLLOWED BY PANCREATIC ABSCESS: OPERATION: RECOVERY". Br Med J. 1 (2508): 211–2. PMC 2317898. PMID 20764267.
  6. Ochsner AJ (1921). "DRAINAGE OF ABSCESS OF PANCREAS". Ann Surg. 74 (4): 434. PMC 1399727. PMID 17864533.
  7. Warshaw AL, O'Hara PJ (1978). "Susceptibility of the pancreas to ischemic injury in shock". Ann Surg. 188 (2): 197–201. PMC 1396740. PMID 686887.
  8. Frey CF, Lindenauer SM, Miller TA (1979). "Pancreatic abscess". Surg Gynecol Obstet. 149 (5): 722–6. PMID 505247.
  9. Warshaw AL (1974). "Inflammatory masses following acute pancreatitis. Phlegmon, pseudocyts, and abscess". Surg Clin North Am. 54 (3): 621–36. PMID 4597041.
  10. 10.0 10.1 10.2 10.3 10.4 Aranha GV, Prinz RA, Greenlee HB (1982). "Pancreatic abscess: an unresolved surgical problem". Am J Surg. 144 (5): 534–8. PMID 7137463.
  11. ALTEMEIER WA, ALEXANDER JW (1963). "Pancreatic abscess. A study of 32 cases". Arch Surg. 87: 80–9. PMID 14012297.
  12. Bittner R, Block S, Büchler M, Beger HG (1987). "Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis". Dig Dis Sci. 32 (10): 1082–7. PMID 3308374.
  13. Bittner R, Block S, Büchler M, Beger HG (1987). "Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis". Dig Dis Sci. 32 (10): 1082–7. PMID 3308374.
  14. McClave SA, McAllister EW, Karl RC, Nord HJ (1986). "Pancreatic abscess: 10-year experience at the University of South Florida". Am J Gastroenterol. 81 (3): 180–4. PMID 3513543.
  15. Neoptolemos JP, Raraty M, Finch M, Sutton R (1998). "Acute pancreatitis: the substantial human and financial costs". Gut. 42 (6): 886–91. PMC 1727149. PMID 9691932.
  16. 16.0 16.1 16.2 16.3 Mithöfer K, Mueller PR, Warshaw AL (1997). "Interventional and surgical treatment of pancreatic abscess". World J Surg. 21 (2): 162–8. PMID 8995072.
  17. 17.0 17.1 Miller TA, Lindenauer SM, Frey CF, Stanley JC (1974). "Proceedings: Pancreatic abscess". Arch Surg. 108 (4): 545–51. PMID 4815930.
  18. Bradley EL, Fulenwider JT (1984). "Open treatment of pancreatic abscess". Surg Gynecol Obstet. 159 (6): 509–13. PMID 6438821.
  19. Johnson CD, Stephens DH, Sarr MG (1991). "CT of acute pancreatitis: correlation between lack of contrast enhancement and pancreatic necrosis". AJR Am J Roentgenol. 156 (1): 93–5. doi:10.2214/ajr.156.1.1898576. PMID 1898576.
  20. 20.0 20.1 Camer SJ, Tan EG, Warren KW, Braasch JW (1975). "Pancreatic abscess. A critical analysis of 113 cases". Am J Surg. 129 (4): 426–31. PMID 804826.
  21. Siegelman SS, Copeland BE, Saba GP, Cameron JL, Sanders RC, Zerhouni EA (1980). "CT of fluid collections associated with pancreatitis". AJR Am J Roentgenol. 134 (6): 1121–32. doi:10.2214/ajr.134.6.1121. PMID 6770619.
  22. Park JJ, Kim SS, Koo YS, Choi DJ, Park HC, Kim JH; et al. (2002). "Definitive treatment of pancreatic abscess by endoscopic transmural drainage". Gastrointest Endosc. 55 (2): 256–62. doi:10.1067/mge.2002.120887. PMID 11818936.