Acute Necrotizing Pancreatitis: Challenges in Management and Recovery

Merina1, Subathra Devi. M2, Maha Lakshmi3

1Senior Patient Safety Officer, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

2Nurse Educator Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

Necrotizing pancreatitis is a complication of acute pancreatitis. This happens when pancreatitis is very severe. Pancreatitis is inflammation in the pancreas, usually in response to an injury or toxins. Severe inflammation can compromise the blood flow to the pancreas causing ischemia and tissue death (Necrosis). This can be life threatening.

Background

Pancreatic necrosis is the most important risk factor contributing to death in severe acute pancreatitis, and it is generally accepted that infection leading to pancreatic necrosis should be managed surgically. In contrast, the management of sterile pancreatic necrosis accompanied by organ failure is controversial. Recent clinical experience has provided evidence that conservative management of sterile pancreatic necrosis including early antibiotic administration seems promising.

The concept of conservative treatment of severe acute pancreatitis originates from several sources. First, an episode of severe acute pancreatitis progresses in two phases. The first 10 to 14 days are characterized by a systemic inflammatory response syndrome maintained by the release of various inflammatory mediators.  The production of such mediators in large amounts may lead to distant organ failure, and surgery does not seem to be the appropriate intervention at that stage of the disease. Second, intensive care treatment has improved significantly during the past decade, and patients with severe acute pancreatitis are best managed there.  Third, septic complications in the second phase of the disease can be reduced and delayed by using appropriate antibiotics.

Case Presentation: Systemic Inflammatory Response Syndrome (SIRS)

A 37 years aged female, with a known history of biliary pancreatitis, and passed out CBD calculi, and was on treatment here since January 2025, underwent pigtail placement for peripancreatic necrotic fluid collection in tail. Previously the patient had been admitted to a private hospital for drain leak and pigtail position adjusted.

Patient presented with nil output from pigtail for 1 day. On arrival patient clinically had tachycardia, fever, vomiting and upper abdominal pain.

Fig (1): Necrosis

Allergies

Not known medicine and food allergies.

Past Medical History

Nil

Past Surgical history

Nil

Physical Examinations

Vital signs

Temp: 98.6, HR: 84/min, RR : 22/min, BP: 100/60mmhg, SpO2: 98%

GCS :15/15

Initial Evaluation

CTs chest and abdomen taken.

Report

  • Necrotizing pancreatitis
  • Minimal left pleural effusion with bilateral basal atelectasis

Patient was taken up for PCD, procedure done.

Patient was treated with IV fluids, antibiotics, antipyretics and antiemetics.

Cholangiopancreatogram (MRCP): Large peri pancreatic fluid collection in body, tail region and another loculated fluid collection in head region with pigtail tube in-situ with multiple air pockets and prominent MPD in tail and body region that appears to be communicating with the fluid collection in the head region. Minimal left pleural effusion with bilateral basal atelectasis

Fig (4), (5), (6): USG abdomen showed residual collection in tail and head of pancreas

After discussing with the Radiologist and Gastro surgeon patient underwent another pigtail placement in the head of pancreas for fluid collection. Pigtail culture showed Pseudomonas species growth, antibiotics escalated.

Daily output monitored from both PCD. During the stay, the patient had gradual reduction and finally nil output from PCD which was placed in the tail. After observation, it was removed. Then on & off leakage from tail PCD site noted and output from head site PCD > 100 ml per day. Her repeat pigtail culture showed sensitivity to Stenotrophomonas maltophilia growth, antibiotics modified.

MRCP was done, which showed necrotic fluid collection of pancreas communicating with MPD. Need for ERCP – PD stunting discussed. After informed consent and anesthetist clearance, the patient underwent ERCP. During the procedure, guide wire could not be passed beyond the neck of pancreas and repeatedly coiled into collection. Procedure abandoned.

Inj. Octreotide therapy and prognosis discussed with patient attendees. The patient was treated with IV fluids, antibiotics and other supportive measures. With all medical measures, patients symptomatically improved. Patient advised for close follow-up in OPD.  \

Treatment Given

Inj. Metronidazole500 mg
Inj. Merogram1 mg
Inj. Tigetop50 mg
Inj. Pantocid40 mg
Inj. Emeset2 mg
Tab. Pyrigesic1000 mg

Skilled Nursing Care

Necrotizing pancreatitis is a severe and potentially life-threatening condition that requires prompt and comprehensive treatment. Skilled nursing care plays a vital role in managing this condition, reducing complications, and improving patient outcomes.

  • Close monitoring: Skilled nurses closely monitor patients vital signs, laboratory values, and clinical status to quickly identify any changes or complications.
  • Pain management: Effective pain management is crucial in necrotizing pancreatitis. Skilled nurses use a variety of strategies, including medication management and non-pharmacological interventions, to control pain and promote comfort.
  • Nutritional support: Nutritional support is essential in necrotizing pancreatitis, as patients often require enteral or parenteral nutrition to support their recovery. Skilled nurses work with dietitians and other healthcare professionals to develop and implement a comprehensive nutritional plan.
  • Wound care: Necrotizing pancreatitis can lead to significant wound complications. Skilled nurses provide expert wound care, including dressing changes and wound assessment, to promote healing and prevent infection.
  • Complication prevention: Skilled nurses are vigilant in preventing complications, such as infection, respiratory failure, and cardiac problems.

Benefits of Skilled Nursing Care

  • Improved outcomes: Skilled nursing care can improve patient outcomes by reducing complications and promoting recovery.
  • Reduced hospital stay: By providing comprehensive care and preventing complications, skilled nurses can help reduce hospital stay and improve patient satisfaction.
  • Enhanced quality of life: Skilled nursing care can enhance patient’s quality of life by promoting comfort, reducing pain, and supporting their physical and emotional needs.

Conclusion

This case highlights the complexities and challenges in managing acute necrotizing pancreatitis. Prompt recognition, aggressive treatment, and multidisciplinary care are crucial in improving patient outcomes. Despite the high morbidity and mortality associated with this condition, timely intervention and comprehensive care can lead to successful recovery.

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