What is the management of a pancreatic abscess?

Management of Pancreatic Abscess

The management of pancreatic abscess requires a combination of appropriate antibiotic therapy and drainage procedures, with percutaneous catheter drainage (PCD) being the first-line approach for most patients, followed by surgical intervention if necessary. 1

Diagnosis

• CT with IV contrast is the preferred imaging modality to identify and characterize pancreatic abscesses 1
• Laboratory markers including lipase, amylase, white blood cell count, C-reactive protein, and procalcitonin (PCT) should be monitored, with PCT being the most sensitive marker for detecting pancreatic infection 1
• Radiologically guided fine-needle aspiration (FNA) for Gram stain and culture is essential to confirm infection and guide antibiotic therapy 1
• Caution should be exercised during FNA as there is a risk of introducing infection; this procedure should be performed only by experienced radiologists 1

Antibiotic Therapy

For patients without MDR colonization:

• Meropenem 1g q6h by extended infusion or continuous infusion 1
• Doripenem 500mg q8h by extended infusion or continuous infusion 1
• Imipenem/cilastatin 500mg q6h by extended infusion or continuous infusion 1

For patients with suspected MDR etiology:

• Imipenem/cilastatin-relebactam 1.25g q6h by extended infusion 1
• Meropenem/vaborbactam 2g/2g q8h by extended infusion or continuous infusion 1
• Ceftazidime/avibactam 2.5g q8h by extended infusion or continuous infusion + Metronidazole 500mg q8h 1

For patients with documented beta-lactam allergy:

• Eravacycline 1mg/kg q12h 1

Drainage Procedures

Percutaneous Catheter Drainage (PCD)

• PCD should be the initial approach for most pancreatic abscesses 1, 2
• Success rates for primary PCD range from 31% to 92%, with more recent studies showing higher success rates 3, 2
• PCD is particularly effective for:
  • Initial stabilization of septic patients 3
  • Unilocular collections that have undergone complete liquefaction 3
  • Abscesses ≥50mm in diameter 2
  • Drainage of recurrent or residual abscesses after surgical intervention 3

Endoscopic Drainage

• Endoscopic transpapillary drainage can be considered for pancreatic abscesses that communicate with the main pancreatic duct 4
• The procedure involves pancreatic sphincterotomy, saline irrigation of the abscess cavity, and placement of a 10F pancreatic stent 4
• Success rates of approximately 74% have been reported 4

Surgical Drainage

• Surgical intervention is indicated when:
  • PCD fails to achieve clinical improvement 1
  • The abscess contains significant solid necrotic debris that cannot be evacuated through percutaneous drains 1, 5
  • There is extensive pancreatic necrosis (>30% necrosis) 1
• Thorough debridement of necrotic tissue is essential during surgical intervention 1
• Minimally invasive surgical approaches, such as using an operating nephroscope through a percutaneously placed drain track, may be considered 1

Monitoring and Follow-up

• Dynamic CT should be repeated regularly, usually every two weeks, or more frequently if there are signs of sepsis or clinical deterioration 1
• Regular monitoring of vital signs, inflammatory markers, and organ function is essential 6
• Patients with ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1

Common Pitfalls to Avoid

• Delaying drainage of infected collections, which can lead to increased mortality 6
• Attempting percutaneous drainage of collections containing significant solid necrotic debris without considering surgical options 1, 5
• Performing unnecessary percutaneous procedures on asymptomatic fluid collections, which may introduce infection 1
• Failing to recognize when PCD is unlikely to be successful (e.g., in cases with extensive necrosis) 5