Abscess pancreatic

Discuss the clinical implications of pancreatic fluid collections, pancreatic abscess, and pancreatic necrosis in acute pancreatitis. 

Acute pancreatitis can progress to several distinct consequences. Pancreatic fluid collections and pancreatic abscesses can form during the course of acute pancreatitis. Pancreatic necrosis can occur when pancreatic enzymes damage the pancreatic tissue or when pancreatic abscesses become secondarily infected. This infection is usually due to bacteria that are normally found in the gastrointestinal tract, including Escherichia coli, Enterobacteriaceae, Staphylococcus aureus, viridans group streptococci, and anaerobes. 

Pancreatic abscess is a collection of pus that forms in the pancreas 4 to 6 weeks after acute pancreatitis. Pancreatic abscess is usually less life-threatening than pancreatic necrosis or pancreatic pseudocyst and can be managed with percutaneous drainage.5... 

Empiric antibiotics are not necessary if the patient has mild disease or a non-infectious etiology of acute pancreatitis. Antibiotics have not been shown to prevent the formation of pancreatic abscess or necrosis when given early in the course of acute pancreatitis. 

Signs and Symptoms Depend on the site of infection. Infection may produce osteomyelitis or arthritis pneumonia [with chills, productive cough, low blood pressure (hypotension), difficulty breathing (dyspnea), or chest pain] meningitis or cerebral abscesses (with headache, fever, vomiting, stupor, coma) or intra-abdominal infections (with biliary drainage, hepatic abscess, pancreatic abscess, peritoneal exudate). 

Removal of biliary tract gallstones with endoscopic retrograde cholangiopancreatography or surgery usually resolves AP and reduces the risk of recurrence. Surgery may be indicated in AP to treat pseudocyst, pancreatic abscess, and to drain the pancreatic bed if hemorrhagic or necrotic material is present. 

Pancreatic abscess A circumscribed intraabdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis or pancreatic trauma. 

Local complications—including acute fluid collection, pancreatic necrosis, abscess, and pseudocyst (collection of pancreatic juice and tissue debris enclosed by a wall of fibrous or granulation tissue)— develop about 4 to 6 weeks after the initial attack. Pancreatic abscess is usually a secondary infection of necrotic tissue or pseudocysts and correlates with the severity of the pancreatitis. Most deaths result from... 

Fig. 1.81. Pancreatic abscess. CT shows a complex, gas-containing fluid collection in the pancreatic tail (arrow)...

Pancreatic abscesses are often multilocular while the abscess content is highly viscous, requiring large drain-... 

According to Lee (2004), success rates of pancreatic abscess drainage range between 32% (infected necrosis) and 90% (pancreatic abscess). For complete drainage, often large and multiple catheters are required. 

A patient with acute pancreatitis may develop many severe local and systemic complications. Local complications involve fluid collection, necrosis, or abscess in the pancreas. A pancreatic fluid collection (or pancreatic pseudocyst) is a collection of tissue, pancreatic enzymes, and blood that forms weeks after acute pancreatitis. Many pancreatic pseudocysts resolve spontaneously, but some require surgical drainage.5 Rupture of a pancreatic pseudocyst with associated erosion and hemorrhage of major abdominal blood vessels can have a mortality approaching 60% thus, continued monitoring of a pseudocyst is prudent.6... 

The goals of treatment for acute pancreatitis include (1) resolution of nausea, vomiting, abdominal pain, and fever (2) ability to tolerate oral intake (3) normalization of serum amylase, lipase, and white blood cell count and (4) resolution of abscess, pseudocyst, or fluid collection as measured by CT scan. 

Local complications in severe AP may include acute fluid collection, pancreatic necrosis, abscess, pseudocyst formation, and pancreatic ascites. 

Malabsorption of protein and fat occurs when the capacity for enzyme secretion is reduced by 90%. A minority of patients develop complications including pancreatic pseudocyst, abscess, and ascites or common bile duct obstruction leading to cholangitis or secondary biliary cirrhosis. 

Adverse reactions may also include tachycardia hypertension palpitations syncope cerebrovascular accident vasodilation vasculitis gingivitis dyspepsia oral ulcer/abscess gastritis gastric ulcer hypersalivation dry mouth splenomegaly melena hematochezia esophagitis colitis pancreatitis pancytopenia neutropenia eosinophilia thrombocytopenia hepatitis hepatomegaly hepatic dysfunction renal... 

Physical examination of the abdomen reveals tenderness most marked in the epigastrium but sometimes present throughout. Bowel sounds are decreased or absent. Usually there are no masses palpable their presence most often indicates complications of AP, such as a pseudocyst or an abscess. In necrotizing pancreatitis the abdomen may be distended due to the intraperitoneal collection of fluid. The temperature is usually slightly elevated (100-101°F) in uncomplicated cases. Physical examination may reveal pleural effusion, especially on the left side. 

Severe acute pancreatitis Acute pancreatitis associated with organ failure and/or local complications, such as necrosis, abscess, or pseudocyst. 

Of the approximately 36 Torulopsis species known so far, T. glabrata, also classified as a Candida species, is a human pathogen. Dissemination leads to colonization of the fungus in many organs and the development of liver abscesses. Severe hepatobiliary torulopsosis was also diagnosed in one patient with diabetes and bile duct stricture, secondary to chronic pancreatitis. (59)... 

Pancreatic and hepatic abscesses a late complication in 10 patients with chronic pancreatitis. Gastroenterology 1992 103 560—565... 

Reddy, K.R., Jeffers, L., Livingstone, A.S., Gluck, C.A., ScUff, E.R. Pyogenic liver abscess complicating common bile duct stenosis secondary to chronic calcific pancreatitis. A rare presentation. Gastroenterology 1984 86 953-957... 

Plasma albumin concentration is decreased in the presence of hepatic cirrhosis, liver abscess, acute pancreatitis, gastrointestinal disease, the nephrotic syndrome and chronic renal failure. Hypoalbuminaemia is a characteristic of neonatal animals, apart from foals, whereas the plasma concentration of cq-acid glycoprotein is markedly elevated in newborn piglets. Hyperbilirubinaemia could further decrease the albumin binding capacity of acidic drugs and some basic drugs in neonatal animals. 

Enteral feedings may also prevent infection by decreasing translocation of bacteria across the gut wall. Preliminary data suggest that probiotics such as lactobacillus (along with a fiber supplement) may reduce bacterial translocation and possibly decrease pancreatic necrosis and abscess. If enteral feeding is not possible, total parenteral nutrition (TPN) should be implemented before protein and calorie depletion becomes advanced. Intravenous lipids should not be withheld unless the serum triglyceride concentration is greater than 500 mg/dL. At present, there is no clear evidence that nutritional support alters outcome in most patients with AP unless malnutrition exists. ... 

When possible, discontinue medications listed in Table 39-2. Antisecretory drugs may be used to prevent stress-related mucosal bleeding. Octreotide may be tried in severe AP, but its efficacy remains uncertain (see Pig. 39-3). Antibiotics should not be used in the absence of signs of infection except in patients with biliary tract gallstones, or in severe AP when pancreatic necrosis or abscess is... 

The causes of intraabdominal abscess overlap those of peritonitis and, in fact, may occur sequentially or simultaneously. Appendicitis is the most frequent cause of abscess. Other potential causes of intraabdominal abscess include pancreatitis, diverticulitis, lesions of the biliary tract, genitourinary tract infections, perforating tumors in the abdomen, trauma, and leaking intestinal anastomoses. In addition, pelvic inflammatory disease in women may lead to tuboovarian abscess. For certain diseases, such as appendicitis and diverticulitis, abscesses occur more frequently than generalized peritonitis. 

M05A B Antiinflammatory enzymes A variety of animal and plant proteases are used to reduce inflammation and swellings in wounds and abscesses after minor dental surgery, for example. The plant enzymes include papain, bromelains and ficin. These and animal enzymes such as trypsin and chy-motrypsin (pancreatic enzymes) are used as debriding agents in burn tissue, pus etc. 

It is not uncommon to find pancreatic pseudocysts after an episode of traumatic pancreatitis or chronic pancreatitis, and some pseudocysts complicating hemolytic uremic syndrome or mediastinal pseudocysts have been reported. CT will reveal a round hypodense structure with a thin or thick wall, which may enhance after contrast injection. Some of these pseudocysts can cause complications, presenting with obstruction of the common bile duct, infection, abscess formation, rupture of the pseudocyst, and can be responsible for splenic vein thrombosis or splenic hemorrhage. CT is the primary imaging tool to visualize and identify these complications (Geier et al. 1990). 

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