Elsevier

Clinical Imaging

Volume 30, Issue 2, March–April 2006, Pages 114-119
Clinical Imaging

Original article
Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values

https://doi.org/10.1016/j.clinimag.2005.09.026Get rights and content

Abstract

The objective of this study was to assess the efficacy of percutaneous catheter drainage, of early infected pancreatic fluid collections, in critically ill patients with severe acute pancreatitis. The patients in our series had a mean Ranson's score of 5.4. Nineteen (63.3%) of the 30 patients were cured with percutaneous drainage. In this group, the mean C-reactive protein value at the beginning of treatment was 172.8 U/l and 102.5 U/l at the end (P<.001). Cultures yielded multiple organisms in 23 patients (76.7%). The most frequently seen organisms were Escherichia coli, Staphylococcus aureus, and Enterococcus faecium.

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

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