A 42-year-old man was referred to our hospital for treat- ment of a necrotizing pancreatitis. He had no history of medication or alcohol consumption. Laboratory studies revealed white blood cell count 20,200/mm 3 , hemoglobin 17.4 g/dL, platelet count 25,8000/mm 3 , serum total bilirubin 2.17 mg/dL, AST 266 U/L, ALT 196 U/L, amylase 1670 U/L, and lipase 2673 U/L. An abdominal CT scan showed acute necrotizing pancreatitis with large amount of peripancreatic necrotic fluid collections (Figure 1(a)). He was admitted to the intensive care unit (ICU) and protease inhibitor and empiri- cal antibiotics treatment was initiated. He presented a cardiac arrest requiring cardiopulmonary resuscitation for 20 min- utes, and continuous renal replacement therapy (CRRT) and mechanical ventilation were needed for combined multior- gan failure. An abdominal CT scan following 4 weeks of med- ical treatment in ICU demonstrated a huge pseudocyst (Fig- ure 1(b)). Despite endoscopic transgastric internal drainage and percutaneous drainage, fever and abdominal pain were not subsided. A follow-up abdominal CT scan after 8 weeks from admission revealed the decreased but still remaining large amount of necrotic collections (Figure 1(c)) and SVT with engorgement of perigastric veins (Figure 1(d)). An emer- gency operation for necrosectomy and external drainage was performed. On operative field, severe adhesion and bleeding tendency was noted. On postoperative day 13, hematemesis occurred. Blood pressure was 90/60 mmHg and hemoglobin decreased from 11.2 g/dL to 7.6 g/dL. An abdominal CT scan revealed extravasation of contrast media at gastric cardia and fundus (Figure 2(a)). After initial resuscitation, an emer- gency esophagogastroduodenoscopy (EGD) was performed. It showed a huge clot in the stomach, and active bleeding from gastric fundus was suspected. However, the focus of bleeding could not be identified exactly due to the presence of large clot and ongoing active bleeding (Figure 2(b
Postponing all interventions for infected necrosis until the stage of walled-off necrosis has been standard practice for many years. The rationale for this delay lies in the pre- vention of the “ extra hit ” (i.e. a pro-inflammatory reaction) of open surgery in these already critically ill patients, and in the relationship between early open necrosectomy and mortality . In line with this practice, catheter drainage in the current step-up approach has also been postponed until the stage of walled-off necrosis. Meanwhile, intraven- ous antibiotics are administered to reduce systemic illness from the infected necrosis, which may lead to increased in- cidence of Candida infections and antibiotic resistance . Notably, several observational studies have suggested that encapsulation is not mandatory for safe and successful catheter drainage [3, 11 – 15]. In other conditions, such as pancreatic fistula after pancreatic resection, early (percu- taneous) catheter drainage has also proven to be safe and successful . Furthermore, an international survey among expert pancreatologists demonstrated “ equipoise ” between immediate and postponed catheter drainage of in- fected necrotizing pancreatitis . The aim of immediate catheter drainage is to prevent further clinical deterioration.
10 Read more
The patient’s body temperature increased to 39.0 °C 3 days after surgery. Her symptoms of pancreatitis wors- ened, and an abdominal enhanced computed tomog- raphy (CT) scan revealed severe necrotizing pancreatitis (Fig. 1a, b and c). The aetiology of pancreatitis showed that her initially ionized calcium levels were increasing, with a value of 1.8 mmol/L (normal 1.10–1.34 mmol/L) as well as low serum phosphorus levels. Further labora- tory evaluation showed an increased PTH level (500 pg/ mL; normal levels, 12 – 65 pg/mL) with a normal 25- hydroxyvitamin D (34 nmol/L) plasma level (normal levels, 12.3 – 107 nmol/L). Detailed relevant laboratory tests are shown in Table 1. The diagnosis of PHPT was confirmed. Technetium-99 m-sestamibi ( 99m Tc-MIBI) scintigraphy revealed an abnormal accumulation in the right inferior parathyroid region at 15 min, and rapid
Background: Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis.
Abstract: Acute pancreatitis is a common disease that can progress to gland necrosis, which imposes significant risk of morbidity and mortality. In general, the treatment for pancreatitis is a supportive therapy. However, there are several reasons to escalate to surgery or another intervention. This review discusses the pathophysiology as well as medical and interventional management of necrotizing pancreatitis. Current evidence suggests that patients are best served by delaying interventions for at least 4 weeks, draining as a first resort, and debriding recalcitrant tissue using minimally invasive techniques to promote or enhance postoperative recovery while reducing wound-related complications.
The indications for the use of prophylactic antibiotics in acute necrotizing pancreatitis (ANP) have been controversial. The use of prophylactic antibiotics should take into consideration the bacterial spectrum, concentration in pancreatic tissue, and emerging resistance patterns. In developing countries, availability and cost of the antibiotic are important issues, especially when comparing this to the cost of potential infectious complications in the setting of limited resources for the care of critically ill patients. Acute necrotizing pancreatitis has an 8 to 25% mortality reported in the developed world. 1,2 A mortality of 20% has been reported
and clinical outcomes of different treatments in our surgical centre and assess the best treatment options. From the current results analysis, SIAPRD is a very effective and safe method, and it is necessary to widely promote it. At the same time, it should be noted that necrotizing pancreatitis is a complex and heterogeneous disease. We are supposed to treat patients individually according to the degree of disease progression and the anatomical distribution of necrotic foci. Minimally invasive surgery is only a means, not a constant. Many patients will require more than one modality to effect disease resolution, and operative debridement continues to play an important role in management of these patients. Evaluation by a multidisciplinary treatment team composed of experienced gastroenterologists, surgeons, and interventional radiologists is crucial for treatment planning and to achieve optimal patient outcomes. One patient in the SIAPRD group died of abdominal bleeding on the 5th day after surgery.
Edema progresses to necrosis in about 20% of patients with acute pancreatitis . The pancreas is infected in 40–70% of patients with necrotizing pancreatitis, and the mortality rate may be up to 40% when the necrotic tissue becomes super- infected . The most important cause of death in necrotiz- ing pancreatitis is secondary infections, which generally result from translocation of enteric bacteria from the intestine via mainly lymphatic, hematogenous, or transmural routes . On the other hand, prophylactic antibiotic therapy was not found to decrease mortality in controlled clinical trials . Although selective gut decontamination and, to some extent, enteral nutrition were shown to decrease infectious complica- tions [19,20], no specific agent that can strengthen the gut barrier or inhibit translocation of micro-organisms from the gut lumen has yet been identified.
Severe necrotizing pancreatitis is related to a high mortality rate, ranging from 20% in patients with sterile necrosis up to 40% in case of infected necrosis associated with multi- organ failure (MOF) [1, 2]. Therefore, occurrence of severe sepsis doubles the risk of death, and this mortality is even higher with increasing age [2, 3]. Early open surgery has been initially proposed for necrotizing pancreatitis, but poor outcomes were observed due to the high risk of bleeding and pancreatic or colonic fistula, leading to a peri- operative morbidity of 50–60% and a mortality rate equal to 20–25% [4, 5]. Since early open surgery could worsen prognosis, nowadays, other less invasive procedures, such as percutaneous drainage (PD), endoscopic transgastric necrosectomy (ETN), or video-assisted retroperitoneal debridement (VARD) are suggested [5, 6]. Therefore, open surgical necrosectomy with repeated laparotomies is considered the last choice whereas other therapeutic options have failed. Currently, the step-up approach, which includes PD possibly followed by VARD or endoscopic transluminal drainage followed by ETN, is proposed as a standard of care for necrotizing pancreatitis . However, few trials have compared the step-up approach with open necrosectomy; therefore, a consensus on the best timing and management of these techniques is lacking [6, 7]. Moreover, the percutaneous step-up approach is certainly useful for lateral fluid or necrotic collections, but its role for medial collections (such as those posteriorly to the stomach) is much more controversial, and ETN could be more suitable in these cases . Combined approaches could conjugate benefits from both endoscopic and percu- taneous or minimally invasive drainages, thus representing a possible solution for severe necrotizing pancreatitis, but they are anecdotal and rarely reported in literature above all in case of pancreatitis-related complications . Par- ticularly, biliary fistula involving the common bile duct is a rare complication of acute necrotizing pancreatitis, its pathogenesis is supposed to be related to the necro- tizing inflammatory process and its management is considered to be extremely difficult . Here, we present the first case in our knowledge of a patient affected by severe necrotizing pancreatitis complicated by biliary fistula, successfully treated by a combined minimally invasive approach conjugating ETN, PD, VARD, and endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting.
14 Read more
How to Cite this article: Management of Acute Necrotizing Pancreatitis through Ayurveda Regimen: A Case Report/ Soniya Gupta, Akash Kumar Gupta, R. K. Yadava/ Ayurlog: National Journal of Research In Ayurved Science 2019; 3(2): pages: 01-07 Ethical approval:
Background: Acute hemorrhagic necrotizing pancreatitis (AHNP) is a severe acute inflammatory of pancreas that can lead to extrapancreatic organ disfunction. The lung and intestine is the most common involved organs, and abdominal lymphatic flow may contribute to AHNP- associated organ injury. In this study, we investigated the impact of thoracic duct ligation and drainage on lung and intestine injury in rats with AHNP. Methods: Thirty-two male Wistar rats were randomly divided into 4 groups: sham operation group, AHNP group, AHNP + ligation group and AHNP + drainage group. Rat AHNP model was induced by retrograde injection of 3.5% sodium deoxycholate into the biliopancreatic duct, and the sham operation group was injected only with saline. In AHNP + ligation group and AHNP + drainage group, thoracic duct was ligated or drainaged before model induction. At 6 h after model induction, the bronchoalveolar lavage fluid (BALF) were collected for determination of tumor necrosis factor-alpha (TNF-alpha), and the tissues of lung, intestine and pancrease were harvested individually for pathohistological evaluation and the myeloperoxidase (MPO) activity determination. In addition, the activity of serum amylase and diamine oxidase (DAO) was determined in each group.
Relative adrenal insufficiency (RAI), defined as inad- equate adrenal corticosteroid production, is common in critically ill patients due to a variety of conditions, in- cluding severe acute pancreatitis (SAP) [1–4]. In SAP patients, RAI is associated with increased morbidity and mortality . Dysfunction of the hypothalamic-pituitary- adrenal (HPA) axis is a major contributing factor to adrenal insufficiency under such conditions . Another key factor is organic damage to the adrenal gland. In animal models of acute necrotizing pancreatitis (ANP), adrenal insufficiency could be largely attrib- uted to pathologically verifiable damage to the adrenal gland [6, 7], caused by a variety of pathological pro- cesses, including ischemia, hemorrhage, inflammation, and apoptosis [1, 8, 9].
10 Read more
The most important matter in the management of pancreatic necrosis and peripancreatic necrosis intervention is the adequate moment to do surgery (Bugiantella, 2015; . At first, the conservative treatment for necrotizing pancreatitis should be the first to be executed Karakayali, 2014). The interventions to necrotic tissue are divided in open surgery (transperitoneal laparotomy or retroperitoneal approach with an incision in flank) and minimally invasive (percutaneous proceedings, laparoscopic, retroperitoneal, transmural endoscopy or combined approach), (Masamichi, With regards to the adequate moment, it’s essential to emphasize that the debridement of the pancreatic necrosis less than three weeks of clinical evolution increases the risk of bleeding and other adverse events Karakayali, 2014; Masamichi, 2015). Moreover, postpone the intervention allows the separations between necrosis and viable tissue, in a way that if the necrosectomy is executed, the chance of removal of the viable tissue is minimized, allowing a better endocrine and exocrine , 2015; Karakayali, 2014; Buskens,
A possible disadvantage of the present study concept is the large number of centres participating. In the Netherlands centralisation has not reached a level that all patients are referred to tertiary centres [8,26]. However, the 20 hospi- tals participating are amongst the largest of the 101 Dutch hospitals and all have experienced gastrointestinal sur- geons, gastroenterologists and radiologists, including for example interventional radiology facilities to treat immi- nent bleeding. Furthermore, since in the Netherlands dis- tances between any participating hospital and the nearest university medical centre is always within 10–100 kilome- tres, referral of patients is generally accepted and easy. A second possible disadvantage is the exclusion criteria 'pre- vious placement of percutaneous drains'. This may apply to a considerable number of patients. The steering com- mittee will repeatedly address this issue in meetings with referring physicians. Finally, in a trial with a rare disease such as infected necrotizing pancreatitis accrual is expected to be difficult. If after the first year less than 85% of the expected patients are recruited the study group will invite (inter-)national centres to join PANTER.
10 Read more
The revised classification categorizes AP into interstitial edematous (IEP) and necrotizing pancreatitis based on contrast enhanced computed tomography (CECT) imaging. IEP constitutes 80-90% of AP, in which the pancreas appears relatively homogenously enhanced on CECT with or without mild peripancreatic stranding or peripancreatic fluid collection. Necrotizing pancreatitis on the other hand is characterized by lack of enhancement of the pancreas and/or (peri) pancreatic tissues on CECT. Both the pancreatic parenchyma and peripancreatic tissues together are involved more frequently than involvement of either alone. Recognition of the degree of necrosis (pancreatic alone, peripancreatic alone, or both) is important since the prognosis varies.
156 Read more
another surgical procedure (e.g., haemorrhoidectomy, vasectomy), perirectal abscess, decubitus ulcer, or intestinal perforation. The intestinal perforation may be due to occult diverticulitis, recto sigmoid neoplasm, or a foreign body such as a chicken bone or toothpick. Necrotizing fasciitis of such intestinal sources may occur in the lower extremity, in the groin or abdominal wall. The spread of infection from intestinal sources to the lower extremity is via extension along the psoas muscle and to that of abdominal wall is via a colo-cutaneous fistula. In particular necrotizing fasciitis may develop in the clinical setting of alcoholism, diabetes mellitus, and parenteral drug abuse.
114 Read more
deep abscess formation can occur, and bacteremia is not uncommon . Fusobacterium necrophorum is a well- established agent of disease above the diaphragm: it is commonly associated with Lemierre’s syndrome, a septic infection caused by thrombose formation within the jugular vein after colonization of a peritonsillar abscess [11–13]. In recent epidemiological surveillance studies, Fusobacterium has been determined to be the predomin- ant organism causative of pharyngitis in a university clinic with 21% of the cases . Much more rarely though, Fusobacterium necrophorum has been described as a potential causative agent of infections below the dia- phragm. Beldman et al. described a case of septic arth- ritis of the hip caused by Fusobacterium necrophorum following a tonsillectomy  and Patel et al. also re- ported in an abstract a case of necrotizing fasciitis and pyomyositis in the thigh caused by Fusobacterium necrophorum in a healthy adult . To the best of our knowledge, no other reports have been described directly linking Fusobacterium necrophorum as the causative organism for necrotizing infections below the knee in the literature. Early diagnosis and treatment is critical due to the rapid extensive tissue destruction that ensues with these infections, and thus maintaining a high index of suspicion is vital for the survival of these patients. A high index of suspicion is required when choosing antibiotic coverage for necrotizing fasciitis and pyomyositis, and additional case reports of this occur- rence may define a pattern of risk factors that should prompt Fusobacterium coverage.
QUALITÉ DES PREUVES On a consulté PubMed à l’aide des rubriques necrotizing fasciitis et necrotizing soft tissue infections, en combinaison avec early diagnosis. Les résultats se limitaient aux études humaines de langue anglaise. D’autres articles prove- naient de la bibliographie des articles retenus. Les preuves sont de niveaux II et III. PRINCIPAL MESSAGE On classe la fasciite nécrosante selon sa microbiologie (poly- microbienne ou monomicrobienne), son anatomie et la profondeur de l’infection. La FN polymicrobienne touche surtout des sujets immunodéprimés. La FN monomicro- bienne est plus rare et touche des sujets sains qui ont souvent une histoire de trau- matisme (généralement mineur). La FN peut se manifester par des symptômes de septicité, de toxicité systémique ou des signes d’infl ammation de la peau, avec une douleur disproportionnée par rapport au degré d’infl ammation. Ces signes se ren- contrent aussi dans les affections moins graves. Les cas hyper-aigus sont d’emblée en septicité et évoluent rapidement vers une insuffi sance touchant plusieurs organes, alors que les cas subaigus demeurent indolores, avec une suppuration des tissus mous. Puisqu’il s’agit d’une affection rare ayant peu de signes spécifi ques, le diagnostic est souvent erroné. Si ont soupçonne une FN, il faut faire l’histologie d’un échantillon de tissu. Des examens de laboratoire et de radiologie peuvent aider à décider si un patient requiert une consultation en chirurgie. Une fois le diagnostic de FN établi, les étapes suivantes comprennent le débridement précoce de la plaie, l’excision du tissu non viable et un traitement avec un antibiotique à large spectre par voie intraveineuse.
classification criteria have been developed, proposed and validated, the diagnostic differentiation between MPA and GPA is not as well-established. A clinical picture involving a positive ANCA test result and a positive biopsy result with evidence of necrotizing vasculitis, necrotizing glomerulonephritis, or granulomatous inflammation strongly suggests a diagnosis of GPA .
Sclera is the opaque posterior five sixth of the outer fibrous coat of the eyeball. Inflammation of the sclera is known as scleritis. Based on site of inflammation Watson and Hayreh have classified scleritis into ant rior scleritis and posterior scleritis. Anterior scleritis is subdivided into four: diffuse anterior scleritis, nodular anterior scleritis, necrotizing anterior scleritis with inflammation, and necrotizing anterior scleritis wit out inflammation, which is also known as scleromal cia perforans. (1) The common symptoms of scleritis