Original articlePercutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values
Introduction
Acute pancreatitis refers to inflammation of the pancreas with variable secondary involvement of adjacent tissues and/or remote organ systems [1].
The underlying pathology of most causes (i.e., alcohol and gallstones) is initial injury to peripheral acinar cells followed by fat necrosis and autodigestion [2]. Acute pancreatitis may be classified histologically as interstitial edematous or as necrotizing according to the inflammatory changes in the pancreatic parenchyma [1]. The edematous form of the disease occurs in about 80–85% of patients and is self-limited; recovery typically occurs within a few days. In 15–20% of patients with the more severe form, hospitalization may be prolonged and associated with infection and other complications, including multiple organ failure [3].
Several severity-of-illness classifications for acute pancreatitis are used to identify patients at risk for complications. Ranson's score is based on 11 clinical signs with prognostic importance [4]. C-reactive protein (CRP) is the standard for serum marker assessment of severity and prognosis in acute pancreatitis [5], [6].
Severe acute pancreatitis is associated with organ failure or local complications such as acute fluid collections, pancreatic necrosis, pseudocyst, or abscess [1].
Traditionally, infected necrosis was an indication for surgical debridement or necrosectomy [7], [8], [9], [10], but it was already demonstrated that complete success may be achieved in some cases of infected necrosis and infected pancreatic fluid collections by catheter drainage alone [11], [12], [13], [14], [15]. Catheter drainage may also temporize preoperatively, optimizing surgical timing [16].
This article presents the results of percutaneous catheter drainage (PCD) of infected pancreatic fluid collections. The patients who underwent intervention in this series had infected liquefied pancreatic necrosis or infected acute fluid collections. They all had severe disease, and initial treatment was conservative based on maximum intensive care support. It was also our purpose to ascertain if there is a relation between clinical improvement and CRP values, and to describe the bacteriological spectrum of infection in acute pancreatitis.
Section snippets
Materials and methods
The records of 30 patients with clinically severe acute pancreatitis who underwent percutaneous drainage from January 1, 1993, to December 31, 2003, were reviewed. All patients had complicated acute pancreatitis, with infected liquefied pancreatic necrosis or infected acute fluid collections, and were admitted to the gastroenterology intensive care unit (ICU) of the University Hospital of Santa Maria, Lisbon, Portugal. Patients with later complications of acute pancreatitis, that is to say
Results
The mean Ranson's score at 48 h after onset of the attack was 5.4 (range, 1–10).
Thirty-three collections were identified in 30 patients. Necrosis was present in 21 patients.
PCD was performed, on average, 18 days after hospital admission.
Cultures yielded single organisms in seven patients, and 23 (76.7%) had multiple organisms, including one patient with four bacteria identified in a single aspirate. The most frequently seen organisms were Escherichia coli (11 patients), Staphylococcus aureus (7
Discussion
This series deals with seriously ill patients, with a mean Ranson's score of 5.4. It is known that the number of Ranson's signs is related with the incidence of systemic complications and the presence of pancreatic necrosis [4], and the disease is deemed severe if three or more Ranson's criteria are observed within 48 h of the onset of the attack [1]. Patients with a score of 5 or greater almost always require management in an ICU [17]. Most of our patients had initial cardiopulmonary
References (41)
- et al.
A critical evaluation of laboratory tests in acute pancreatitis
Am J Gastroenterol
(2002) - et al.
Surgical approach in patients with acute pancreatitis. Is infected or sterile necrosis an indication—in whom should this be done, when and why
Gastroenterol Clin North Am
(1999) Percutaneous catheter-directed debridement of infected pancreatic necrosis: results in 20 patients
J Vasc Interv Radiol
(1998)Pancreatic imaging. New modalities
Gastroenterol Clin North Am
(1999)- et al.
Surgical management of necrotizing pancreatitis
Surg Clin North Am
(1999) - et al.
The role of gut in the development of sepsis in acute pancreatitis
J Surg Res
(1991) Early diagnosis of pancreatic infection by computed tomography guided aspiration
Gastroenterology
(1987)A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis
Arch Surg
(1993)- et al.
Pathology of acute and chronic pancreatitis
Pancreas
(1993) Genetic determinants of mortality in acute necrotizing pancreatitis
Int J Pancreatol
(1994)
Practice guidelines in acute pancreatitis
Am J Gastroenterol
Prognostic factors in acute pancreatitis
J Clin Gastroenterol
Acute necrotizing pancreatitis. Treatment strategy according to the status of infection
Ann Surg
Management of necrotizing pancreatitis
World J Gastroenterol
Management of fluid collections and necrosis in acute pancreatitis
Curr Gastroenterol Rep
Imaging and intervention in acute pancreatitis
Radiology
Abdominal fluid collection secondary to acute pancreatitis: treated with percutaneous catheter drainage
Chin Med J
Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results
Am J Roentgenol
Infected pancreatic fluid collections: percutaneous catheter drainage
Radiology
Temporizing effect of percutaneous drainage of complicated abscesses in critically ill patients
AJR Am J Roentgenol
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