General case of the day. Emphysematous pancreatitis

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.

Acute Renal Infection in Adult, Part 2: Emphysematous Urinary Tract Infection—What the Radiologist Needs to Know

Renal emphysema, as described by Kelly and MacCallum in 1898, refers to the spontaneous generation of gas within the renal parenchyma and surrounding tissues. Since its initial description, it has become apparent that the spectrum of radiologically visible renal and perirenal gas includes three distinct clinical entities: (1) emphysematous pyelonephritis, a necrotizing infection associated with gas formation in the renal parenchyma, (2) emphysematous pyelitis, in which gas is confined to the renal pelvis and calyces, and (3) gas-forming perinephric abscess. In this article, we will review gas-forming infections of the urinary system in terms of radiological features, clinical manifestations, predisposing factors, and appropriate management guidelines.

Necrotizing Fasciitis of Thoracic and Abdominal Wall with Emphysematous Pyelonephritis and Retroperitoneal Abscess

Emphysematous pyelonephritis is a life-threatening severe form of pyelonephritis usually occurring in patients with diabetes mellitus with or without obstructive uropathies in whom there is necrotizing infection leading to the gas production of an unclear mechanism involving the renal parenchyma and the collecting system. Necrotizing fasciitis is characterized by progressive necrosis of fat and fascia due to deep-seated infection of subcutaneous tissue. It has a fulminant course with considerable mortality. Diabetes Mellitus is a common predisposing factor. The combined occurrence of emphysematous pyelonephritis and necrotizing fasciitis is extremely unusual. Early recognition and management is mandatory to avoid mortality. We report a case of a 53-year-old female, a known case of Type II diabetes mellitus, who presented with necrotizing fasciitis of thoracic and abdominal wall with emphysematous pyelonephritis in the left kidney with a retroperitoneal abscess.

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

Emphysematous pancreatitis (EP) is a subtype of acute necrotizing pancreatitis (ANP) characterized by the presence of gas in and around the pancreas. Although investigators have studied prognostic factors in ANP, less is known about EP. We aimed to determine predictors of mortality and identify changes in management strategies for EP. A PubMed search was performed to identify EP cases. Data were gathered about patient demographics, clinical findings, laboratory results, radiological studies, procedures, outcomes, and mortality. Data were analyzed using univariate and multivariate logistic regression analyses. Including a case from our institution, the study cohort included 64 subjects. The overall mortality rate was 32.8% (21/64). On univariate analysis, age (P = 0.019), hypotension (P = 0.007), gas outside the pancreas on computed tomography imaging (P = 0.003), initial surgical evacuation (P = 0.007), and the development of multiorgan failure (P = 0.008) were associated with mortality. On multivariate analysis, only the development of multiorgan failure was found to be an independent predictor of mortality (P = 0.039). The overall mortality rate of 32.8% for EP is similar to the mortality rates published for ANP. The development of multiorgan failure in EP is strongly associated with increased mortality. Percutaneous and endoscopic approaches have been replacing surgical interventions.

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.

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.

Simultaneous emphysematous cholecystitis and emphysematous pancreatitis: a case report

Emphysematous infections of the abdomen and pelvis are potentially life-threatening conditions that require aggressive medical and surgical management. Therefore, early radiographic detection of emphysematous infections is important in management. Emphysematous cholecystitis is a rare and severe form of acute cholecystitis caused by gas-forming organisms. Emphysematous pancreatitis is a rare form of pancreatitis with gas in pancreatic parenchyma. We report a rare case of simultaneous occurrence of emphysematous cholecystitis and emphysematous pancreatitis.

Thyrotoxic hypokalaemic periodic paralysis

A 24-year-old male Chinese student from southern China presented with sudden onset of generalized weakness. The evening before admission he had played football for 3 hours, and eaten a Chinese takeaway plus two hamburgers. He awoke in the early hours of the following morning unable to move his arms or legs. There was no history of any recurring illness and in particular there were no symptoms suggestive of hyperthyroidism.

On examination the only abnormality was a profound symmetrical muscle weakness more marked proximally than distally (Medical Research Council (MRC) classification grade 1–2). Sensation to light touch and pinprick was normal. There were no signs of thyrotoxicosis.

Laboratory investigations revealed the following (normal values in parentheses): serum potassium 1.2 mmol/litre (3.5–5.0); urinary potassium 14 mmol/litre (20–60); phosphate 0.18 mmol/litre (0.8–1.45); sodium, urea, and creatinine levels were normal. Electrocardiogram showed first degree atrioventricular block, prolonged QT interval and right axis deviation.

He was given 120 mmol of intravenous potassium supplement over 12 hours. Over the next 24 hours his serum potassium returned to 4 mmol/litre, with complete resolution of the weakness.

Subsequent investigations showed the following thyroid hormone measurements: thyroid-stimulating hormone (TSH) <0.08 mU/litre (0.5–6.0), triiodothyronine (T3) 3.7 nmol/litre (1.0–2.5), free thyroxine (T4) 53.7 pmol/litre (9.0–25.0), and thyroid peroxidase antibodies 124 IU/ml (0–75). He was HLA B46 and D9 positive. Ultrasonography of the thyroid gland revealed a mildly enlarged, heterogeneous thyroid with no discrete nodules and increased vascularity throughout.

He was started on treatment with propranolol and carbimazole and returned home to China to seek further medical treatment.

Thyrotoxic hypokalaemic periodic paralysis

A 24-year-old male Chinese student from southern China presented with sudden onset of generalized weakness. The evening before admission he had played football for 3 hours, and eaten a Chinese takeaway plus two hamburgers. He awoke in the early hours of the following morning unable to move his arms or legs. There was no history of any recurring illness and in particular there were no symptoms suggestive of hyperthyroidism.

On examination the only abnormality was a profound symmetrical muscle weakness more marked proximally than distally (Medical Research Council (MRC) classification grade 1–2). Sensation to light touch and pinprick was normal. There were no signs of thyrotoxicosis.

Laboratory investigations revealed the following (normal values in parentheses): serum potassium 1.2 mmol/litre (3.5–5.0); urinary potassium 14 mmol/litre (20–60); phosphate 0.18 mmol/litre (0.8–1.45); sodium, urea, and creatinine levels were normal. Electrocardiogram showed first degree atrioventricular block, prolonged QT interval and right axis deviation.

He was given 120 mmol of intravenous potassium supplement over 12 hours. Over the next 24 hours his serum potassium returned to 4 mmol/litre, with complete resolution of the weakness.

Subsequent investigations showed the following thyroid hormone measurements: thyroid-stimulating hormone (TSH) <0.08 mU/litre (0.5–6.0), triiodothyronine (T3) 3.7 nmol/litre (1.0–2.5), free thyroxine (T4) 53.7 pmol/litre (9.0–25.0), and thyroid peroxidase antibodies 124 IU/ml (0–75). He was HLA B46 and D9 positive. Ultrasonography of the thyroid gland revealed a mildly enlarged, heterogeneous thyroid with no discrete nodules and increased vascularity throughout.

He was started on treatment with propranolol and carbimazole and returned home to China to seek further medical treatment.

Emphysematous infections of the abdomen and pelvis: a pictorial review

Emphysematous (gas-forming) infections of the abdomen and pelvis represent potentially life-threatening conditions that require aggressive medical and often surgical management. The initial clinical manifestation of these entities may be insidious, but rapid progression to sepsis will occur in the absence of early therapeutic intervention. Conventional radiography and ultrasonography are often the initial imaging modalities used to evaluate patients with abdominopelvic complaints. However, when a differential diagnosis remains, or if further localization or confirmation of tentative findings is needed, computed tomography (CT) should be considered the imaging modality of choice. CT is both highly sensitive and specific in the detection of abnormal gas and well suited to reliable depiction of the anatomic location and extent of the gas. Of equal importance may be the capability of CT to help reliably identify benign sources of gas, because treatment (if any) varies dramatically depending on the source. Knowledge of the pathophysiologic characteristics, common predisposing conditions, and typical imaging features associated with gas-forming infections of the gallbladder, stomach, pancreas, and genitourinary system will help make early diagnosis and successful treatment possible. In addition, such knowledge will aid in further diagnostic work-up, surveillance of potential complications, and evaluation of therapeutic response.