Pneumoperitoneum from gas gangrene of the pancreas: three unusual findings in a single case

Free intraperitoneal air in infected pancreatic necrosis with intraperitoneal rupture: A rare presentation of a complex diseases

Key Clinical Message

Among the multitude of causes for acute abdomen patients presenting with free intraperitoneal air, one almost never finds infected pancreatic necrosis as one of the culprits. In patients with risk factors for acute pancreatitis presenting with generalized peritonitis with free intraperitoneal air, consideration should be given to this often deadly entity.

Abstract

Acute pancreatitis is a morbid acute abdominal pathology that has been increasing in incidence in recent years. Most patients have a mild disease and treated medically, while a few proportion require interventional procedures. We present the case of a 39-year-old male patient who presented with progressive abdominal pain, vomiting, and yellowish discoloration of the eyes. The abdominal condition progressed to the point where clinical signs became consistent with generalized peritonitis and an x-ray finding of free intraperitoneal air. The patient underwent exploratory laparotomy with intraoperative findings of intraperitoneal rupture of infected pancreatic necrosis with intraperitoneal purulent collection. He was managed with necrosectomy and discharged improved after intensive care and general ward stay.

Clostridium perfringens necrotizing pancreatitis: an unusual pathogen in pancreatic necrosis infection

Pancreatic necrosis infection (PNI) accounts for about 20-40 % of severe acute pancreatitis. PNI caused by anaerobic bacteria is unusual but when they present, Clostridium perfringens is the microorganism most commonly involved. We present a 60-year-old patient with a previous history of SARS-CoV-2, diagnosed with acute pancreatitis. During the hospitalisation he developed Clostridium perfringens bacteraemia. A CT-scan showed pancreatic gas gangrene and a surgical necrosectomy was performed. Clostridium perfringens was isolated in cultures of the pancreatic tissue and collections. The patient's clinical status improved after surgery and the appropriate medical therapy. He was discharged 76 days after admission. Nowadays, the 'step-up approach' is an accepted therapeutic tool in treatment of pancreatic necrosis and peripancreatic fluid collections. However, most authors suggest that Clostridum perfringens infection requires a more aggressive approach due to the high mortality associated to clostridial infection.

Clostridium perfringens's necrotizing acute pancreatitis: a case of success

The authors report a case of a 62-year-old man with upper abdominal pain with few hours of onset and vomits. The initial serum amylase was 2306 U/L. The first CT showed signs of a non-complicated acute pancreatitis. He suffered clinical deterioration and for this reason he was admitted on the intensive care unit where he progressed to multiple organ failure in <24 h. A new CT scan was performed that showed pneumoperitoneum and pneumoretroperitoneum. He underwent an exploratory laparotomy and pancreatic necrosectomy and vacuum pack laparostomy were performed. Intraoperative peritoneal fluid culture was positive for Clostridium perfringens confirming the diagnosis. He was discharged from hospital after 61 days. According to our research this is the second case reported in literature of a spontaneous acute necrotizing pancreatitis caused by C. perfringens, with pneumoretroperitoneum and pneumoperitoneum on evaluation by CT scan, that survived after surgical treatment and vigorous resuscitation.

Medical versus surgical management for emphysematous pancreatic necrosis: is gas within pancreatic necrosis an absolute indication for surgery?

OBJECTIVES

The aim of this study was to evaluate whether pancreatic necrosis with presence of gas is an absolute indication for surgery or if there is a possibility for the medical management of this pathology.

METHODS

This study is a retrospective study including 56 patients with diagnosis of pancreatic necrosis and gas on computed tomography from April 2003 to March 2011. We recorded all the factors related to each group of treatment, including APACHE II score, C-reactive protein level, Tomographic Severity Index, organ and multiorgan failure, and infected necrosis after fine-needle puncture, to evaluate the differences between surgical and medical treatment.

RESULTS

Thirty-six (64%) of these patients were submitted to surgery, whereas 20 (36%) were managed conservatively. Twenty-eight patients (78%) who underwent surgery had infected necrosis. Thirty-five percent of the patients (7 patients) in the medical group had organ failure versus 83% of the patients in the surgical group.

CONCLUSIONS

Pancreatic necrosis with gas on computed tomography is a relative indication for surgery. Medical management is a feasible and safe possibility for this pathology in selected cases. The presence of organ failure and infected necrosis often precludes a surgical treatment.

Emphysematous pancreatitis predisposed by Olanzapine

A 32-year-old male presented to our intensive care unit with severe abdominal pain and was diagnosed as acute pancreatitis after 2 months of olanzapine therapy for bipolar disorder. His serum lipase was 900 u/L, serum triglyceride 560 mg/dL, and blood sugar, fasting and postprandial were 230 and 478 mg/dL, respectively on admission. Contrast enhanced computed tomography (CECT) of abdomen was suggestive of acute pancreatitis. Repeat CECT showed gas inside pancreas and collection in peripancreatic area and patient underwent percutaneous drainage and antibiotics irrigation through the drain into pancreas. We describe the rare case of emphysematous pancreatitis due to development of diabetes, hypertriglyceridemia and immunosuppression predisposed by short duration olanzapine therapy.

Fulminant type of emphysematous pancreatitis has risk of massive hemorrhage

Emphysematous pancreatitis (air in the parenchyma) was previously considered an indication for surgery, but some recent studies have reported good clinical outcomes with non-operative management. As a step toward establishing a better treatment strategy, we report a case of fulminant pancreatitis with massive hemorrhage into the emphysematous space. A 75-year-old man was admitted with worsening abdominal pain with obstructive jaundice and renal failure 28 h after the onset. He was diagnosed as having emphysematous pancreatitis with slight pancreatic necrosis. Despite conservative treatment with intensive care, sudden cardiac and respiratory failure occurred, and he died 53 h after onset. The autopsy findings revealed biliary sludge and massive bleeding in the retroperitoneal space around the pancreas, suggesting that temporary obstruction of the bile duct with sludge induced emphysema and the hemorrhage rapidly spread into the broadened emphysematous space. Whereas conservative management has been thought to be appropriate in selected cases of emphysematous pancreatitis, when there is pancreatic emphysema in the early phase, a fulminant course tends to develop. Since there is a risk of massive bleeding into the emphysematous space, endoscopic or invasive drainage performed to collapse the emphysematous space could benefit the outcome.

Management of infected pancreatic necrosis

The past two decades have seen major advances in the understanding and clinical management of acute pancreatitis, yet it still lacks a specific treatment, and management is largely supportive and reactive. Surgery is seeing a diminishing role in the early phase of acute pancreatitis but still predominates in the management of infected pancreatic necrosis--the most lethal complication. This review focuses on recent literature but begins with an account of the evolution of infected necrosis management, which serves to place current treatment into context. Although surgeons initially emphasized less invasive approaches to pancreatic necrosis, they now compete with new techniques developed by pioneering physicians, radiologists, and interventional endoscopists. Clinicians adopting the new techniques will need to emulate the dedication and commitment that the current pioneers demonstrate. Although new techniques are still evolving, they should be evaluated against existing standards of treatment.