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Query: UMLS:C0001339 (acute pancreatitis)
 10,593 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Infected pancreatic necrosis was diagnosed clinically and radiologically in a patient admitted for acute pancreatitis. As free gas in the pancreatic area was recognized, antibiotic therapy (ceftriaxone) was empirically introduced, while surgical drainage was being planned. After the second week, the patient rapidly started to improve, to the point that he could be discharged home without operation. Control CT-scans and general laboratory tests, at this phase and later on, confirmed a still enlarged gland but free of infection or ongoing inflammation. Cholelithiasis, which had been identified in an early ultrasound scan, was electively treated by cholecystectomy 2 mo after the onset of pancreatitis, in the absence of sepsis, and with uneventful recovery. This case illustrates the rare possibility of spontaneous regression of infected necrotic pancreatitis, without any type of operation or nonoperative drainage.
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PMID:Clinical regression of infected pancreatic necrosis. Case report. 151 60

Pancreatic necrosis is now recognized as a principal determinant of survival in acute pancreatitis. However, it is currently unknown how frequently pancreatic necrosis develops in acute pancreatitis, how often pancreatic necrosis becomes secondarily infected, and whether sterile pancreatic necrosis represents an indication for surgery or can be treated by conservative means. In 194 patients with unequivocal acute pancreatitis, pancreatic necrosis developed in 38 (20%), as documented by dynamic pancreatography, and was confirmed by histologic diagnosis at surgery in 28. All patients were prospectively treated by medical means. Patients with pancreatic necrosis who remained persistently febrile underwent fine needle aspiration for bacterial culture. Infected pancreatic necrosis was demonstrated in 27 of the 38 patients (71%) with pancreatic necrosis and was treated by open drainage, yielding a mortality rate of 15%. All 11 patients with demonstrated sterile pancreatic necrosis, including 6 with pulmonary and renal insufficiency, were successfully treated without surgery. Pancreatic necrosis occurs in approximately 20% of patients with acute pancreatitis and is necessary for the development of secondary pancreatic infection. However, pancreatic necrosis by itself, even when accompanied by organ failure, is not an absolute indication for surgery. A trial of medical treatment for all patients with sterile pancreatic necrosis is in order.
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PMID:A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis. 198 54

Acute pancreatitis is in the majority of patients a mild, self-limiting illness. Five to fifteen percent of the patients develop acute necrotizing pancreatitis, a severe illness with a high morbidity and mortality. Secondary infection of the pancreatic necrosis (infected pancreatic necrosis) is the main cause of death. Pancreatic necrosis is identified with a high accuracy by contrast-enhanced computed tomography. The differentiation between sterile and infected necrosis requires demonstration of bacteria or fungi isolated from the necrosis. Surgical treatment of a sterile necrosis remains controversial, but there is a tendency towards conservative non-operative treatment. Infected pancreatic necrosis is regarded as an absolute indication for surgery, untreated the mortality is approximately 100%. The aim of modern treatment is to remove the pancreatic necrosis continuously. This has successfully been done by the open packing method, with or without subsequent drainage. At present no randomized trials comparing the different treatment modalities are available. The question of prophylactic antibiotics still remains unanswered. For the present imipenem 0,5 g x 3 is recommended.
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PMID:[Necrotizing pancreatitis]. 757 Oct 95

Infected pancreatic necrosis and sepsis are the leading causes of death in patients with necrotizing pancreatitis. Between 1986 and 1993, 123 patients with infected pancreatic necrosis were treated; in all cases the infected necrosis extended to the retroperitoneal area. Surgical treatment was performed a mean of 18.5 days after the onset of acute pancreatitis. Operative management consisted of wide-ranging necrosectomy through all the affected area, combined with continuous widespread lavage and suction drainage applied for a mean of 39.5 days, with a median of 6.5 litres of normal saline per day. In 56 cases (46 per cent), another surgical intervention (distal pancreatic resection, splenectomy, cholecystectomy, sphincteroplasty or colonic resection) was also performed. Bacteriological findings revealed mainly enteric bacteria, but Candida infection was detected in 21 per cent of patients. The overall hospital mortality rate was 7 per cent (nine patients died). Infected pancreatic necrosis responds well to aggressive surgical treatment, continuous, long-standing lavage and suction drainage, together with supportive therapy combined with adequate antibiotic and antifungal medication.
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PMID:Surgical strategy and management of infected pancreatic necrosis. 881 77

Infected pancreatic necrosis, developing in the early stages of severe acute pancreatitis is a diffuse suppurative process and is difficult to eradicate. Pancreatic abscess, on the other hand, is a late appearing and easily drainable localised infection. Our rule of thumb is that the later the operation, the shorter the course of antibiotics. Following an operation for infected pancreatic necrosis we recommend a 5-week course of antibiotics. After drainage of a pancreatic abscess antibiotics are given for at least 10 days.
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PMID:Duration of antibiotic treatment in surgical infections of the abdomen. Pancreatic infections. 890 73

Infected pancreatic necrosis is a devastating and lethal complication of acute pancreatitis. Late death is usually a result of sepsis. W.A. Altemeier and J.W. Alexander established in 1963 that open drainage of the necrotic pancreas is mandatory for survival (Arch Surg 1963;87:96-105). In 1981, E.D. Davidson and E.L. Bradley III concluded that "marsupialization" is the most effective method of open drainage (Surgery 1981;89:252-6). At our institution, we have a series of 10 patients who have undergone marsupialization for treatment of infected pancreatic necrosis. Our mortality rate was 30 per cent. One death resulted from sepsis after an infected necrotic pancreas was found with a colonic anastomotic leak at emergency exploratory celiotomy. Of note, further debridement was not performed. A second death occurred in a female with idiopathic pancreatitis and leukocytopenia, and we are uncertain whether that played a role in the failure of surgical intervention. The third death was in a young alcoholic with hyperlipidemia and severe pancreatitis who was septic 8 days before surgery. The patient died on postoperative day 1. Of the survivors, some were old, many were septic, and all but one returned for further debridement. Our series supports open debridement of infected pancreatic necrosis as a life-saving maneuver and marsupialization as an effective means of open drainage.
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PMID:Marsupialization of the pancreas for infected pancreatic necrosis. 903 96

There is some evidence that the incidence of acute pancreatitis is increasing worldwide. Improved treatment concepts, especially in the severe course of the disease, have significantly reduced formerly high mortality. According to the different clinical courses it is of the utmost importance for the therapeutic approach to this disease to differentiate between mild (morphologically characterized as edema) and severe (intra- and extrapancreatic necroses) as early as possible. In this respect, contrast-enhanced CT scanning and the determination of so-called necrosis indicating parameters (e.g. C-reactive protein) have been established as the "gold-standard". While patients with acute edematous pancreatitis are successfully treated in a normal ward, patients with a proven necrotizing course of the disease should undergo intensive monitoring and maximum intensive care therapy in the ICU. Additionally, these latter patients should receive antibiotics which are capable of penetrating the pancreas and the pancreatic necroses in bactericidal concentrations. It seems more and more evident that only patients under this treatment regimen who develop infected pancreatic necrosis and sepsis are candidates for surgical intervention. Infected pancreatic necrosis can be easily diagnosed with a high level of safety and reliability by fine needle puncture and aspiration of pancreatic necrosis and fluid collections under imaging-guided procedures. Patients with sterile necrosis respond in most cases to intensive care therapy and in these patients the indication for surgery will be only exceptional. Surgery should be performed as late as possible to ensure sufficient demarcation of the necroses. In our experience the best surgical treatment modality for infected pancreatic necrosis is necrosectomy combined with postoperative continuous local lavage of the retroperitoneum. Mortality of severe acute pancreatitis has been reduced under this treatment concept to below 10%.
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PMID:[Surgical therapy of severe acute pancreatitis]. 924 82

The intestinal tract is the motor of sepsis in the "gut-MOF hypothesis". Acute pancreatitis causes an early severe reduction of intestinal microcirculation with consequent production of radicals and cytokines damaging intestinal integrity. The intestinal organ dysfunction syndrome results in a breakdown of barrier function and a loss of propulsive activity. This leads to microbial overgrowth and bacterial translocation. This liberates cytokines and causes secondary pancreatic infection after lymphatic and systemic bacterial dissemination. Infected pancreatic necrosis by enteric microorganisms is the main cause of pancreatic sepsis.
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PMID:[Pathogenesis of pancreatogenic sepsis]. 993 55

Acute pancreatitis is a disease capable of the widest clinical expression, ranging from mild discomfort to multiorgan failure and death. Moreover, the process may remain localized in the pancreas, or spread to regional tissues, or even involve remote organs. Despite several efforts, the pathophysiology of acute pancreatitis and its complications remains obscure. In the absence of an understanding of the pathogenesis and the reasons for the variations in severity, the study and management of acute pancreatitis has necessarily been empirical. There is little doubt that the development of pancreatic necrosis in patients with acute pancreatitis results in an increase in clinical severity and an escalation of the mortality risk when compared to interstitial pancreatitis. Furthermore, the mortality risk of patients with sterile pancreatic necrosis is markedly different from that of patients developing secondary infections in pre-existing pancreatic necrosis. Infected pancreatic necrosis is uniformly fatal, if untreated. While most authorities agree that surgical debridement is required for survival in patients with secondary pancreatic infections, the precise form of the subsequent drainage has become a matter of some controversy. In this paper we discuss the most recent insights relating to the nosographical classification of pancreatic necrosis and secondary pancreatic infections, along with an analysis of the findings in the literature regarding the surgical treatment of these conditions.
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PMID:[Treatment of pancreatic necrosis and secondary pancreatic infections]. 1223 54

During 2002 the International Association of Pancreatology developed evidenced-based guidelines on the surgical management of acute pancreatitis. There were 11 guidelines, 10 of which were recommendations grade B and one (the second) grade A. (1) Mild acute pancreatitis is not an indication for pancreatic surgery. (2) The use of prophylactic broad-spectrum antibiotics reduces infection rates in computed tomography-proven necrotizing pancreatitis but may not improve survival. (3) Fine-needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. (4) Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. (5) Patients with sterile pancreatic necrosis (with negative fine-needle aspiration for bacteriology) should be managed conservatively and only undergo intervention in selected cases. (6) Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications. (7) Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. (8) Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis. (9) In mild gallstone-associated acute pancreatitis, cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission. (10) In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. (11) Endoscopic sphincterotomy is an alternative to cholecystectomy in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone-associated acute pancreatitis. There is however a theoretical risk of introducing infection into sterile pancreatic necrosis. These guidelines should now form the basis for audit studies in order to determine the quality of patient care delivery.
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PMID:IAP Guidelines for the Surgical Management of Acute Pancreatitis. 1243 71


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