Causes and Management of Necrotizing Pancreatitis

Etiology

Necrotizing pancreatitis is primarily caused by gallstones and excessive alcohol consumption, which together account for 75-80% of all cases. 1

Primary Causes

Gallstones represent a leading cause, with obstruction of the common bile duct leading to pancreatic inflammation and potential necrosis 1
Alcohol abuse is the other major cause, with chronic consumption predisposing patients to more severe forms of pancreatitis including necrotizing disease 1
Idiopathic cases account for approximately 20-25% when no specific cause can be identified 1

Other Causes

Hypertriglyceridemia 2
Trauma 2
Infections 2
Post-ERCP (iatrogenic) 3

Diagnostic Workup for Etiology

Initial investigations should include pancreatic enzymes in plasma, liver function tests, and ultrasound of the gallbladder 1
Follow-up investigations should include fasting plasma lipids, fasting plasma calcium, viral antibody titers, repeat biliary ultrasound, MRCP, and CT with pancreas protocol 1
Do not accept a diagnosis of idiopathic pancreatitis without at least two good quality ultrasound examinations to exclude gallstones 1

Management Strategy

Initial Management and Monitoring

All patients with necrotizing pancreatitis should be managed in a high dependency unit or intensive care unit with full monitoring and systems support. 4, 5

Continuous monitoring should include hourly assessment of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 5
Laboratory markers including hematocrit, blood urea nitrogen, creatinine, and lactate should be monitored as indicators of tissue perfusion 5
Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast 5

Fluid Resuscitation

Adequate fluid resuscitation is essential, but avoid aggressive over-resuscitation which can lead to abdominal compartment syndrome 4

Nutritional Support

Early enteral nutrition should be initiated rather than parenteral nutrition, as it improves outcomes in necrotizing pancreatitis. 4

A trial of oral nutrition is recommended immediately in patients without nausea, vomiting, or signs of severe ileus 6
When oral nutrition is not feasible, enteral feeding should be initiated via nasogastric or nasojejunal tube 5
Both gastric and jejunal feeding can be delivered safely 5
Total parenteral nutrition should be reserved only for patients who cannot tolerate enteral nutrition 5

Antibiotic Management

Prophylactic antibiotics should NOT be routinely administered in sterile pancreatic necrosis; antibiotic therapy should be reserved only for cases with signs/symptoms of infection. 4, 6

If antibiotic prophylaxis is used in patients with substantial pancreatic necrosis (>30% of gland necrotic), it should continue for no more than 14 days 3, 5
When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be used (carbapenems, quinolones, and metronidazole) 6
Routine use of antifungal agents is not recommended 6

Management Based on Infection Status

Sterile Necrosis

Sterile necrosis does not usually require therapy and should be managed conservatively. 3

Focus on fluid resuscitation, nutritional support, and monitoring for complications 5
Surgery has no role in severe pancreatitis with sterile necrosis 3
Mortality rate for sterile necrosis is 0-11% 5, 1

Infected Necrosis

The development of infected necrosis should be suspected in patients with preexisting sterile pancreatic necrosis who have persistent or worsening symptoms or symptoms and signs of infection, typically after 7-10 days of illness. 3

Diagnosis of Infected Necrosis

In patients with persistent symptoms and greater than 30% pancreatic necrosis, image-guided fine needle aspiration should be performed 5
The sample should be cultured and Gram stained to document infection 3
Fine-needle aspiration shows a sensitivity of 96% for detecting pancreatic infection 7
CT-guided fine-needle aspiration is unnecessary in the majority of cases when infection is strongly suspected (gas in collection, bacteremia, sepsis, or clinical deterioration) 6

The Step-Up Approach: Delay, Drain, Debride

Interventions for infected necrosis should be delayed until at least 4 weeks after disease onset when possible, as this significantly reduces mortality. 4, 8

Timing of Intervention

Postpone surgical interventions for at least 4 weeks after disease onset 4
Debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality 6
Early intervention (within 4 weeks) is associated with higher mortality and more complications 8

Step 1: Percutaneous or Endoscopic Drainage

In infected pancreatic necrosis, percutaneous drainage is recommended as the first line of treatment. 4

Percutaneous drainage can completely resolve infection in 25-60% of patients without requiring further surgical intervention 4
Endoscopic ultrasound (EUS)-guided cystogastrostomy is preferred for central collections abutting the stomach 4
Percutaneous drainage is appropriate for collections in the early acute period (<2 weeks) or for those with deep extension into paracolic gutters 4, 6
Self-expanding metal stents (lumen-apposing metal stents) appear to be superior to plastic stents for endoscopic transmural drainage 6

Step 2: Minimally Invasive Necrosectomy

When drainage is insufficient, minimally invasive surgical strategies should be employed, as they result in less new-onset organ failure compared to open surgery. 4

Direct endoscopic necrosectomy should be reserved for patients with limited necrosis who do not adequately respond to drainage alone 6
Multiple minimally invasive surgical techniques are feasible, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement 6
In selected cases with walled-off necrosis and disconnected pancreatic duct syndrome, a single-stage surgical transgastric necrosectomy may be an option 4

Step 3: Open Surgical Necrosectomy

Open operative debridement maintains a role in cases not amenable to less invasive endoscopic and/or surgical procedures 6

Indications for Intervention

Absolute Indications

Infected pancreatic necrosis (primary indication) 4
Abdominal compartment syndrome unresponsive to conservative management 5
Acute ongoing bleeding when endovascular approach is unsuccessful 5
Bowel ischemia or acute necrotizing cholecystitis 5

Relative Indications

Complications including gastric outlet, biliary, or intestinal obstruction 4
Disconnected pancreatic duct syndrome 4
Ongoing organ failure without signs of infected necrosis (after 4 weeks) 4
Persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure 6

Special Considerations for Gallstone Pancreatitis

Urgent ERCP (within 24 hours) should be performed in patients with gallstone pancreatitis who have concomitant cholangitis. 3

Early ERCP (within 72 hours) should be performed in those with a high suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated common bile duct, jaundice) 3, 5
All patients with biliary pancreatitis should undergo definitive management of gallstones (cholecystectomy) during the same hospital admission if possible, and otherwise no later than 2-4 weeks after discharge 3, 5
In patients unfit for surgery, ERCP and sphincterotomy alone provides adequate long-term therapy 3

Prognosis and Mortality

Overall mortality in acute necrotizing pancreatitis is approximately 30-40%, significantly higher than the 10-15% mortality rate for all types of acute pancreatitis. 4, 1

Mortality by Type

Sterile pancreatic necrosis: 0-11% mortality 5, 1
Infected pancreatic necrosis: 40% average mortality, potentially exceeding 70% in severe cases 4, 1
Infected necrosis with organ failure: 35.2% mortality (highest risk scenario) 4, 1

Timing of Deaths

Approximately one-third of deaths occur in the early phase (first week) from multiple organ failure 5, 1
Most deaths after the first week are due to infectious complications 5, 1

Referral Considerations

Patients with infected necrosis should be managed in centers with specialist units with appropriate endoscopic, radiologic, and surgical expertise. 3

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications who may require intensive therapy unit care, or interventional radiological, endoscopic, or surgical procedures 5, 1
A multidisciplinary approach including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition is essential 6

What are the causes and management of necrotizing pancreatitis?

Help us tailor your experience