an interesting case of walled off necrosis in a nonalcoholic patient of acute pancreatitis

1. A CASE OF RECURRENT ACUTE
PANCREATITIS WITH WALLED OFF
NECROSIS UNDERGOING A NON
OPERATIVE FAVOURABLE OUTCOME
DR. AVISIKTA MALLICK
(2ND YEAR JUNIOR RESIDENT)
DEPARTMENT OF GENERAL
SURGERY
MEDICAL COLLEGE, KOLKATA
Guided by-
PROF SHIBAJYOTI GHOSH
DR ARKAPROVO ROY
DEPARTMENT OF GENERAL SURGERY
MEDICAL COLLEGE, KOLKATA

2. CASE SUMMARY
A 40year non alcoholic non smoker male without any comorbidity had a 3wk
history of upper abdominal pain radiating towards back, aggravated with food
intake associated with abdominal distension. Recurrent episodes of bilious
vomiting & fever
H/O similar attacks 5 months and 1yr back. Then he was diagnosed as Acute
pancreatitis with pseudocyst formation.
USG guided pigtail drainage of the pseudocyst done in an outside hospital &
discharged.

3. EXAMINATION REVEALED--
• PR-132/min, BP- 132/77 mm Hg
• Temp elevated
• P/A- tense with severe generalized tenderness
• a/w huge abdominal distension

4. BLOOD BIOCHEMISTRY:
• Hb-10, TLC- 3000(N84L12),CRP-100.2, others-WNL including lipid profile
• Progressive decline in TLC(300028902870)
& platelet count(1.97L5400046000)
• Hypokalemia, transient rise in ALP (1833402008), Amylase and lipase-
declining trend
• Pt developed toxic features

5. IMAGING
• CECT W/A(27/09/2020)- acute necrotizing pancreatitis with necrotic collection at
pancreatic head region involving 50% of parenchyma with extensive
peripancreatic inflammatory stranding
• Extrinsic compression on stomach and duodenum
• 05/10/2020- increase in inflammatory collection, Ascites & b/l pleural effusion
• 10/11/2020- regression in peripancreatic inflammatory collection but necrosis
increased.
• Triphasic MDCT W/A(31/12/2020)- walled off necrosis at head, body and tail of
pancreas. Ascites with splenic vein compression.
• Few RPLN

6. Necrotic pancreas
Walled off necrosis

7. MRI W/A WITH MRCP(16/01/2020)-SAME FINDINGS
WITHOUT CONNECTION WITH MPD.
Walled off necrosis
Necrotic debris

8. MANAGEMENT
• Pt was kept NPO with IV fluids, Nasogastric decompression, IV
broad spectrum antibiotics (Imipenem+Cilastatin & Metronidazole),
analgesicsTPN and IV albumin infusionFFP transfusion
• recovering gradually with improved clinical and biochemical
parameters
• enteral feeding started with occasional pain
• Planning for endoscopic internal drainage- BUT technical issues

9. Suddenly his swelling got reduced with
vomiting of large amount of fluid mixed with
necrotic debris—
? Rupture

10. POST RUPTURE--
• USG W/A(23/01/2021): A fistulous communication noted
between cyst and D1, blocked with inflammatory debris.

11. Fistulous
communicatio
n
1st part of
duodenum

12. MDCT W/A(25/01/2021)- walled of necrosis is much
reduced in size(5x3.7cm)

13. FURTHER PLAN---
• Gradually patient recovered well, No features of toxicity/ localized or generalised
peritonitis
• Patient has been sent to a specialized centre for Endoscopic stenting of the
fistulous communication

14. DISCUSSION:
• DEFINITION: Acute pancreatitis (AP) is an acute inflammatory condition of the pancreas leading
to injury or destruction of acinar components and clinically characterized by abdominal pain and
elevated blood levels of pancreatic enzymes (Banks et al, 2013; Sarner & Cotton, 1984).
• RECURRENT ACUTE PANCREATITIS- more than 2 attacks of AP without any evidence of
chronic pancreatitis (20-30% of AP)
• Major cause of morbidity
• Mortality- 1% to 20% in mild to severe cases, respectively
• ETIOLOGY:
• Alcoholic pancreatitis
• Biliary pancreatitis

15. COMPLICATIONS OF AP
ONSET <4 WEEKS >4 WEEKS
INTERSTITIAL EDEMATOUS ACUTE PERIPANCREATIC
FLUID COLLECTION
PANCREATIC PSEUDOCYST
NECROTIZING ACUTE NECROTIZING
COLLECTION
WALLED OFF NECROSIS
(1-9%)

16. NATURAL HISTORY WALLED OFF NECROSIS
1. Spontaneous resolution-70%
2. Intervention required- 30% cases who become symptomatic or
develop complications
• size ?
• timing of intervention

17. COMPLICATION OF WON
• Infection – may lead to sepsis
• Obstruction- biliary obstruction
• Gastric outlet obstruction
• Hemorrhage- from splenic vein aneurysm
• Rupture-leading to internal fitulization(very rare)
• into GIT/adjacent viscera- cystoenteric/pancreatic/pleural/bronchial
• Free peritoneal cavity- pancreatic ascites

18. • Percutaneous drainage- necrosectomy cannot be done adequately
Risk of introduction of secondary infection
Risk of injury to spleen, colon, pleura
External pancreatic fistula formation
High recurrence rate
• Endoscopic Drainage- Transmural/Transpapillary- success rate 74-
80%
• EUS guided endoluminal drainage
• Minimally invasive surgical necrosectomy
• Step up approach- PANTER trial
• Open necrosectomy- adequate debridement, definitive pathologic
diagnosis
• But associated with haemorrhage, SIRS and enteric fistula
formation if done early

20. CONCLUSION
• “ Acute pancreatitis is the most
terrible of all the calamities that occur
in connection with the abdominal
viscera” (Berkeley
Moynihan)
• poor outcome with both, surgical and conservative
therapies. Thus, surgery should only be performed
as a last resort

21. SO,
• “patience and diligence, like faith, remove
mountains”
• “God put the pancreas in the back
because He did not want surgeons
messing with it”