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Necrotizing pancreatitis: Diagnose, treat, consult

Cleveland Clinic Journal of Medicine. 2017 August;84(8):639-648 | 10.3949/ccjm.84a.16052
August 1, 2017|Cleveland Clinic Journal of Medicine
Tiffany Y. Chua, MD;R. Matthew Walsh, MD, FACS;Mark E. Baker, MD;Tyler Stevens, MD
Author and Disclosure Information

Tiffany Y. Chua, MD
Department of Internal Medicine, Cleveland Clinic

R. Matthew Walsh, MD, FACS
Chairman, Department of General Surgery; Vice-Chairman, Digestive Disease Institute; Rich Family Distinguished Chair of Digestive Diseases; Chairman, Academic Department of Surgery, Education Institute, Cleveland Clinic; and Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Mark E. Baker, MD
Section of Abdominal Imaging, Imaging Institute, Digestive Disease and Cancer Institutes, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Tyler Stevens, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Tiffany Y. Chua, MD, Department of Internal Medicine, NA10, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; chuat@ccf.org

ABSTRACT

Necrosis significantly increases rates of morbidity and mortality in acute pancreatitis. Hospitalists and general internists are on the front lines in identifying severe cases and consulting the appropriate specialists for optimal multidisciplinary care.

KEY POINTS

  • Selective and appropriate timing of radiologic imaging is vital in managing necrotizing pancreatitis. Protocols are valuable tools.
  • While the primary indication for debridement and drainage in necrotizing pancreatitis is infection, other indications are symptomatic walled-off pancreatic necrosis, intractable abdominal pain, bowel obstruction, and failure to thrive.
  • Open surgical necrosectomy remains an important treatment for infected pancreatic necrosis or intractable symptoms.
  • A “step-up” approach starting with a minimally invasive procedure and escalating if the initial intervention is unsuccessful is gradually becoming the standard of care.

SUMMING UP

Necrosis significantly increases rates of morbidity and mortality in acute pancreatitis. Hospitalists, general internists, and general surgeons are all on the front lines in identifying severe cases and consulting the appropriate specialists for optimal multidisciplinary care. Selective and appropriate timing of radiologic imaging is key, and a vital tool in the management of necrotizing pancreatitis.

While the primary indication for intervention is infected pancreatic necrosis, additional indications are symptomatic walled-off pancreatic necrosis secondary to intractable abdominal pain, bowel obstruction, and failure to thrive. As a result of improving technology and inpatient care, these patients may present with intractable symptoms in the outpatient setting rather than the inpatient setting. The onus is on the primary care physician to maintain a high level of suspicion and refer these patients to subspecialists as appropriate.

Open surgical necrosectomy remains an important approach for care of infected pancreatic necrosis or patients with intractable symptoms. A step-up approach starting with a minimally invasive procedure and escalating if the initial intervention is unsuccessful is gradually becoming the standard of care.

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