Title: Emphysematous Pancreatitis

Authors and affiliation

1Urmimala Bhattacharjee MD

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2Atul Saroch MD

3Ashok Kumar Pannu MD#

4Sartghak Wadhera MBBS

1Senior Resident, 2,3Assistant Professor, 4MD Resident, #Corresponding author

Department of Internal Medicine, Post Graduate Institute of Medical Education and Research,

Chandigarh

Address of correspondence:

Dr. Ashok Kumar Pannu

Email: gawaribacchi@gmail.com

Address: 4th floor, F block, Department of Internal Medicine, PGIMER, Chandigarh (India)

Dr. Urmimala Bhattacharjee

Email: drub200954@gmail.com

Dr. Atul Saroch

Email: atulsaroch@gmail.com

Dr. Sarthak Wadhera

Email: sarthakwadhera@gmail.com

Funding: None

© The Author(s) 2019. Published by Oxford University Press on behalf of the Association of Physicians.
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Conflict of interest: None

Author contributions

1UB: patient management, collected patient data, drafted and revised the manuscript

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2AS: patient management

3AKP: patient management, collected patient data, drafted and revised the manuscript

4SW: patient management

Words: 220

Keywords: Pancreatitis, Emphysematous, gas forming organisms, Escherichia coli, Klebsiella

pneumoniae

A 32-year-old male admitted with high-grade fever (up to 103F) and severe epigastric pain

for two weeks in the emergency department. He did not consume alcohol and had no prior

comorbidities. On examination, the patient was drowsy; pulse was 110 per minutes, blood

pressure 80/50 mm of Hg, respiratory rate 26 per minutes, temperature 39°C and oxygen

saturation 92%. The abdomen was distended with marked epigastric tenderness and sluggish

bowel sounds. Laboratory tests revealed leucocytosis and acute kidney injury. However, serum

amylase and lipase were normal. Abdominal computed tomography revealed large necrotic

areas with multiple air pockets replacing the majority of the pancreatic parenchyma and

peripancreatic collections suggesting emphysematous pancreatitis (Figure 1A). Subsequently,

two percutaneous catheters were placed, and the drained pus grew Escherichia coli (Figure

1B). Blood culture also grew Klebsiella pneumoniae. The patient improved with intravenous

antibiotics, mechanical ventilation, and supportive care.

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Emphysematous pancreatitis is a gas forming, severe necrotizing infection of the pancreas and

its surrounding tissues. Most cases are bacterial and Escherichia coli being the commonest

organism, followed by Klebsiella pneumonia, Pseudomonas, Clostridium perfringens and

rarely Candida species. Treatment depends on the disease severity and requires appropriate

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antibiotics, source control (percutaneous or endoscopic trans-gastric drainage of pus and gas)

and intensive supportive care. A minimally invasive step-up approach as compared with open

necrosectomy, carries good outcome.1-3

References

1. Ku YM, Kim HK, Cho YS, Chae HS. Medical management of emphysematous

pancreatitis. J Gastroenterol Hepatol 2007; 22:455-6.

2. Nadkarni N, D’cruz S, Kaur R, Sachdev A. Successful outcome with conservative

management of emphysematous pancreatitis. Indian J Gastroenterol. 2013;32:242-245

3. Van santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong

CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N

Engl J Med. 2010;362:1491-1502.

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Figure 1A. Abdominal computed tomography showing emphysematous pancreatitis with large necrotic areas
with multiple air pockets replacing the majority of the pancreatic parenchyma and peripancreatic collections
(arrows)

93x75mm (300 x 300 DPI)

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281x233mm (300 x 300 DPI)
Figure 1B. Drained pus