Multiorgan Failure Predicts Mortality in Emphysematous Pancreatitis: A Case Report and Systematic Analysis of the Literature

Emphysematous Pancreatitis as a Life-Threatening Condition: A Case Report and Review of the Literature

Emphysematous pancreatitis represents the presence of gas within or around the pancreas on the ground of necrotizing pancreatitis due to superinfection with gas-forming bacteria. This entity is diagnosed on clinical grounds and on the basis of radiologic findings. Computed tomography is the preferred imaging modality used to detect this life-threating condition. The management of emphysematous pancreatitis consists of conservative measures, image-guided percutaneous catheter drainage or endoscopic therapy, and surgical intervention, which is delayed as long as possible and undertaken only in patients who continue to deteriorate despite conservative management. Due to its high mortality rate, early and prompt recognition and treatment of emphysematous pancreatitis are crucial and require individualized treatment with the involvement of a multidisciplinary team. Here, we present a case of emphysematous pancreatitis as an unusual occurrence and discuss disease features and treatment options in order to facilitate diagnostics and therapy.

Fulminant Emphysematous Pancreatitis: Diagnosis Time Counts

Emphysematous pancreatitis (EP), a severe form of necrotizing infection of the pancreas, is an extremely rare medical emergency with high rates of mortality. It is characterized by intraparenchymal pancreatic or peri-pancreatic air due to either monomicrobial or polymicrobial infection with gas-forming bacteria or due to entero-pancreatic fistula. EP is classified according to timing from disease onset when air bubble signs were detected on computed tomography (CT) scan, as early onset (within 2 weeks from disease onset) or late (more than 2 weeks from disease onset). While most cases of acute pancreatitis are resolved with supportive care alone, clinical outcomes of EP, especially the early onset subtype, are very poor with high rates of morbidity and mortality. These two case reports present the clinical features, diagnostic investigations, and management of two patients admitted to our hospital with early onset fulminant EP, each investigated and managed with different approaches. The first patient underwent a more conservative treatment, with diagnosis being made 52 h following admission, and thus, intensive care unit (ICU) admission and surgery were postponed, while the second patient was diagnosed a few hours following presentation with earlier ICU admission. In this article, we will present the critical importance of early diagnosis of the aforementioned rare entity of severe pancreatitis and will consider the consequences of rapid diagnosis on disease course, morbidity and mortality.

Early-onset emphysematous pancreatitis indicates poor outcomes in patients with infected pancreatic necrosis

BACKGROUND

Emphysematous pancreatitis (EP) is a subtype of infected pancreatic necrosis (IPN) characterized by presence of gas in (peri)pancreatic necrosis. However, the impacts of EP on outcomes of IPN are still controversial.

METHODS

A prospective database of consecutive patients with IPN in a tertiary hospital was post-hoc analyzed. Patients were assigned to EP and non-EP groups to perform a comprehensive comparison.

RESULTS

A total of 178 patients with IPN were enrolled and the overall mortality was 30.9%. EP accounted for 20.8% (n = 37) of cases and was significantly associated with higher incidences of Escherichia coli (45.9 versus 18.4%, P = 0.001) and Klebsiella pneumoniae (56.8 versus 33.3%, P = 0.009) infection. There was scarcely any disparity in clinical characteristics and outcomes between IPN patients with and without EP. However, patients with early-onset EP defined as air bubble signs occurring within 2 weeks from disease onset were significantly older and have higher prevalence of history of diabetes, and they were also associated with significantly higher mortality (57.1 versus 8.7%, P = 0.015) compared with late-onset patients.

CONCLUSIONS

The clinical outcomes of EP might be like those of non-emphysematous infection. However, when EP occurs within 2 weeks from disease onset, it is highly lethal.

Necrotizing pancreatitis complicated by retroperitoneal emphysema: two case reports

Background

Emphysematous pancreatitis is acute pancreatitis associated with emphysema based on imaging studies and has been considered a subtype of necrotizing pancreatitis. Although some recent studies have reported the successful use of conservative treatment, it is still considered a serious condition. Computed tomography (CT) scan is useful in identifying emphysema associated with acute pancreatitis; however, whether the presence of emphysema correlates with the severity of pancreatitis remains controversial. In this study, we managed two cases of severe acute pancreatitis complicated with retroperitoneal emphysema successfully by treatment with lavage and drainage.

Case presentation

Case 1: A 76-year-old man was referred to our hospital after being diagnosed with acute pancreatitis. At post-admission, his abdominal symptoms worsened, and a repeat CT scan revealed increased retroperitoneal gas. Due to the high risk for gastrointestinal tract perforation, emergent laparotomy was performed. Fat necrosis was observed on the anterior surface of the pancreas, and a diagnosis of acute necrotizing pancreatitis with retroperitoneal emphysema was made. Thus, retroperitoneal drainage was performed. Case 2: A 50-year-old woman developed anaphylactic shock during the induction of general anesthesia for lumbar spine surgery, and peritoneal irritation symptoms and hypotension occurred on the same day. Contrast-enhanced CT scan showed necrotic changes in the pancreatic body and emphysema surrounding the pancreas. Therefore, she was diagnosed with acute necrotizing pancreatitis with retroperitoneal emphysema, and retroperitoneal cavity lavage and drainage were performed. In the second case, the intraperitoneal abscess occurred postoperatively, requiring time for drainage treatment. Both patients showed no significant postoperative course problems and were discharged on postoperative days 18 and 108, respectively.

Conclusion

Acute pancreatitis with emphysema from the acute phase highly indicates severe necrotizing pancreatitis. Surgical drainage should be chosen without hesitation in necrotizing pancreatitis with emphysema from early onset.

Percutaneous endoscopic necrosectomy in a patient with emphysematous pancreatitis: A case report

RATIONALE

Emphysematous pancreatitis, a rare complication of acute necrotizing pancreatitis with a high mortality rate, is associated with gas-forming bacteria. When using the step-up approach for treating emphysematous pancreatitis, it is preferable to delay drainage interventions for 4 weeks. However, percutaneous drainage may be necessary, even in the early phase of acute pancreatitis, for a patient whose sepsis deteriorates despite optimal medical management. Percutaneous drainage can then be followed by endoscopic necrosectomy through the percutaneous tract.

PATIENT CONCERNS

A 52-year-old man was transferred to our hospital for treatment of sepsis and multiorgan failure associated with emphysematous pancreatitis.

DIAGNOSIS

An abdominal computed tomography scan had shown pancreatic and peripancreatic necrosis, along with extensive gas bubbles.

INTERVENTIONS

Despite optimal medical management, the patient's condition continued to deteriorate, and it became necessary to insert 2 percutaneous catheter drainages (PCDs), even though the patient was still in the early phase of pancreatitis. Each PCD was upsized and irrigated with sterile saline by an interventional radiologist twice a week. The infected necrosis around the tail of the pancreas was completely resolved after PCD. However, PCD through the transperitoneal route did not resolve necrosis around the pancreatic head. Following the PCDs, percutaneous pancreatic necrosectomy using an ultra-slim upper endoscope was performed, after which the patient recovered quickly and was discharged.

OUTCOMES

Follow-up computed tomography was performed 12 weeks after the patient was discharged, and it showed complete resolution of the walled-off necrosis. The patient's condition improved without any fluid collection or complications.

LESSONS

PCD can be used in the early phase of emphysematous pancreatitis for patients who continue to deteriorate due to sepsis. This can easily be followed, if necessary, by percutaneous pancreatic necrosectomy using an ultra-slim endoscope.

Emphysematous Pancreatitis Mimicking Bowel Perforation

Emphysematous pancreatitis is a rare complication of acute necrotizing pancreatitis, which carries a mortality rate of up to 70%. It has only been described in isolated case reports. We report a patient who presented with suspected bowel perforation and was subsequently found to have emphysematous pancreatitis that was managed successfully with multidisciplinary team involvement.

Chemotherapy-induced necrotising tumour lysis and perforation of a huge gastric cancer simulating emphysematous pancreatitis

A 56-year-old man was diagnosed to have a huge gastric cancer extending from the lesser curvature of the stomach to the pancreas with multiple hepatic and peritoneal metastases. Two days after completing chemotherapy with cisplatin plus high dose leucovorin and fluorouracil, drastic necrotising tumour lysis led to gastric perforation and septic shock most likely due to bacterial peritonitis. The image of tumour lysis looked like an emphysematous pancreatitis. Afterwards, immunohistochemical study of the tumour specimen confirmed moderate positivity of dihydropyrimidine dehydrogenase and absence of Bcl-2 expression. The incomplete expression of dihydropyrimidine dehydrogenase and total deficiency of Bcl-2 are considered to be the main underlying causes of such extraordinary chemosensitivity and so severe a tumour lysis phenomenon. Pre-emptive intensive survey of possible biomarkers of chemosensitivity is thus highly recommended upon treating a massive gastric cancer.

Emphysematous Pancreatitis in the Elderly

BACKGROUND

Emphysematous pancreatitis (EP) is an unusual medical emergency that presents with intraparenchymal pancreatic air in the setting of necrotizing infection. We aimed to determine the differences in the epidemiology, etiology, clinical presentation, symptoms and outcome of EP between elderly and nonelderly patients.

MATERIALS AND METHODS

A PubMed search was performed using the keywords "emphysematous pancreatitis," "gas-forming pancreatitis" and "pancreatitis and pneumoperitoneum" from March 1959 to February 2019. Forty-two EP articles with 58 patients were enrolled in our study. We divided the patients into ≥65 (elderly, n = 25) and <65-year age groups (non-elderly, n = 33). Data on patient age, sex, comorbidities, symptoms, clinical findings, etiologies, laboratory results, treatments, outcomes and mortality were collected and analyzed using the Student's t test and chi-square test using IBM SPSS 20. P values < 0.05 (2-tailed) indicated statistical significance.

RESULTS

Alcohol- and biliary pancreatitis-related EP were 4.95- and 4-fold, respectively, more frequent in the elderly than in the nonelderly (36% versus [vs.] 9.1%, P < 0.05). Fever was more frequent in the nonelderly than in the elderly (69.7% vs. 36%, P < 0.05). The elderly presented with more severe shock status (68% vs. 33.3%, P < 0.05) and received more surgical interventions than the nonelderly (60% vs. 30.3%, P < 0.05).

CONCLUSIONS

Biliary pancreatitis is the most common type of EP in the elderly and has an atypical presentation with less fever, more severe shock, and more surgical interventions. In treating elderly patients with pancreatitis, immediate administration of adequate antibiotics, assisted drainage and early surgical intervention are needed to prevent shock.

Emphysematous Pancreatitis: A Rare Complication of Acute Necrotizing Pancreatitis

Emphysematous pancreatitis is a rare and fatal complication of acute necrotizing pancreatitis. We report a radioclinical observation of a 61-year-old female patient who consulted for epigastric pain radiating to the back, associated with vomiting and elevated lipasaemia more than 3 times the normal value. The abdominal computerized tomography (CT) scan carried out on the fourth day of hospitalization, based on worsening of the clinical condition, showed pancreatic necrosis associated with the presence of air bubbles. Percutaneous puncture of a peripancreatic collection was positive for Escherichia coli. A diagnosis of emphysematous pancreatitis was established. The clinical and biological evolution of our patient was favourable with antibiotic treatment.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Emphysematous pancreatitis associated with penetrating duodenal ulcer

In the “proton pump inhibitors era”, a penetrating peptic ulcer (PPU) represents an exceptional cause of abdominal pain, and was more frequently observed in the past where there was not an effective antacid treatment. Ulcer-induced pancreatitis is very rare, too, and manifests with persistent, intense pain radiating to the back. A mild to severe pancreatitis with peripancreatic fluid collection can be observed at imaging. However, only a few cases of association between PPU and emphysematous pancreatitis (EP) have been published in the literature. EP is a rare but potentially fatal form of acute necrotizing pancreatitis in which gas grows in and outside the pancreas, and typically involves the whole parenchyma in diabetic individuals.

Here we report an extremely rare case of a duodenal ulcer penetrating the pancreas and complicated with EP. Unlike the classic form of EP, which involves the whole parenchyma and has a poor prognosis, we found that the emphysematous involvement of the pancreas by PPU has a benign course if a conservative therapy is promptly established. Gas is confined to the site of penetration, usually the pancreatic head, and ulcers most often involve the duodenum.