What are the complications of pancreatitis?

Complications of Pancreatitis

Pancreatitis can lead to numerous serious complications including local pancreatic complications (necrosis, pseudocysts, abscesses) and systemic complications (respiratory failure, renal failure, cardiovascular dysfunction), with infected pancreatic necrosis being the most significant risk factor for mortality. 1, 2

Local Complications

• Pancreatic Necrosis: Diffuse or focal areas of non-viable pancreatic parenchyma, typically associated with peripancreatic fat necrosis. Infected necrosis triples mortality risk 3

• Acute Fluid Collections: Occur in 30-50% of severe pancreatitis cases, located in or near the pancreas without a wall of granulation or fibrous tissue. More than half resolve spontaneously 3, 2

• Pseudocysts: Collections of pancreatic juice enclosed in a wall of fibrous or granulation tissue that arise following an attack of acute pancreatitis, requiring four or more weeks to form 3, 4

• Pancreatic Abscess: A circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis 3, 5

• Hemorrhage: Can occur due to erosion of blood vessels by pancreatic enzymes, potentially leading to massive internal bleeding 6

Systemic Complications

Respiratory Complications

• Pleural effusions and pneumonic consolidation 3, 2
• Acute Respiratory Distress Syndrome (ARDS) 2, 7
• Respiratory failure requiring mechanical ventilation in severe cases 8, 7

Cardiovascular Complications

• Shock and hypotension due to systemic inflammatory response 8, 7
• Prolonged shock can lead to death in severe cases 6

Renal Complications

• Acute renal failure (occurring in approximately 35.8% of severe cases) 9
• Tubular necrosis and nephrosis 6

Hepatobiliary Complications

• Hepatic failure due to extensive liver necrosis 6
• Biliary stasis (18.4% of cases) and jaundice (4.6% of cases) 6

Metabolic and Hematologic Complications

• Deranged clotting 3
• Hypermetabolism and catabolic state 3
• Increasing leucocyte and platelet counts 3

Gastrointestinal Complications

• Prolonged ileus and abdominal distension 3
• Upper digestive tract bleeding 9

Systemic Inflammatory Response

• Severe pancreatitis can trigger a systemic inflammatory response similar to sepsis or severe burns 7
• This can lead to multi-organ dysfunction syndrome (MODS) 4
• Initial pro-inflammatory response may be followed by an anti-inflammatory reaction that can inhibit immune response, increasing risk for systemic infection 4

Mortality Risk Factors

• Independent prognostic factors for mortality include advanced age, acute renal failure, and respiratory failure 9
• Other factors significantly related to mortality include upper digestive tract bleeding and shock 9
• Interestingly, pseudocyst formation may have a protective effect on survival 9

Monitoring for Complications

• All patients require ongoing reassessment on a daily or more frequent basis to diagnose life-threatening complications early 3, 1
• Dynamic CT should be performed within 3-10 days of admission in severe cases and repeated every two weeks or more frequently if sepsis is suspected 3, 1
• Laboratory monitoring should include leucocyte and platelet counts, clotting studies, APACHE II score, and CRP concentration 3, 1

Common Pitfalls in Managing Complications

• Unnecessary drainage of asymptomatic fluid collections, which increases the risk of introducing infection 2
• Mistaking persistent low-grade fever in sterile necrosis for infected necrosis 2
• Failure to recognize non-pancreatic sources of infection such as central line infections or pneumonia 2
• Delay in identifying systemic complications, which can lead to increased mortality 7