52-year-old man with epigastric pain and fever on hospital day 4
A 52-year-old man with a history of alcohol use disorder and two prior episodes of pancreatitis is admitted to the hospital with severe epigastric pain radiating to the back, nausea, and vomiting. On admission, his lipase is 3200 U/L. He is managed with aggressive intravenous fluids and analgesia. Over the next 72 hours, his pain improves, but on hospital day 4, he develops a fever to 39.1°C (102.4°F) and a white blood cell count of 18,500/µL. A contrast-enhanced CT scan of the abdomen is performed, which shows a 10-cm area of nonenhancing pancreatic parenchyma consistent with necrosis, along with several locules of gas within the necrotic collection. The patient is hemodynamically stable. Which of the following is the most appropriate next step in management?
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A
Explanation
Clinical Pearl:
In stable patients with infected walled-off pancreatic necrosis, an endoscopic, transmural, minimally invasive step-up approach is preferred over more invasive surgical interventions for drainage and debridement.
Explanation:
This patient has developed infected pancreatic necrosis, a severe complication of acute pancreatitis. The diagnosis is established by the clinical signs of infection (fever, leukocytosis) and the presence of gas within the necrotic collection on CT scan. For stable patients with organized, walled-off necrosis, current gastroenterology society guidelines recommend a 'step-up' approach, starting with minimally invasive techniques. Given the location of the collection adjacent to the stomach or duodenum (implied by the feasibility of an endoscopic approach), endoscopic transgastric or transduodenal necrosectomy is the preferred initial intervention. This method allows for drainage and direct debridement of solid necrotic material through an endoscopically created fistula. Antibiotics are also indicated but are not the definitive management for a large, organized, infected collection; source control is required. Surgical open necrosectomy is associated with higher morbidity and mortality and is reserved for cases where minimally invasive approaches fail or are not technically feasible. CT-guided percutaneous drainage is an option but is less effective for debriding solid necrotic tissue compared to endoscopic necrosectomy and is often a temporizing measure or used when endoscopic access is not possible. MRCP is used to evaluate the biliary and pancreatic ducts, which is not the urgent priority in a patient with established infected necrosis requiring source control.
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