Clinical presentations of patients with emphysematous pancreatitis can vary widely, from minimally symptomatic to hemodynamic compromise and shock. Typical are findings classically associated with pancreatitis including nausea, vomiting, fever, and epigastric pain. Lab findings will usually reveal a significantly elevated amylase/lipase level and CT scan will show free air within the lesser sac or pancreatic parenchyma. The clinical course of necrotizing pancreatitis is known to be tenuous, frequently complicated by the development of systemic inflammatory response syndrome and multiorgan failure within 1 to 2 weeks of symptom onset.1,2,8 Up to one half of mortality occurs in this time frame2,9 and so early supportive care is essential. Systemic inflammation will improve; however in approximately one third of patients infected necrosis develops, presumably as a result of gut translocation.2,6
Patients with necrotizing pancreatitis who have emphysematous pancreatitis have a highly variable clinical course. Recent case reports/series describe a less aggressive process with fewer complications and subsequently lower morbidity/mortality compared with the course of general necrotizing pancreatitis.3,5,6 The etiology of free air also plays an important role in a patient’s clinical course as well as in the approach to treatment.
Treatment for necrotizing pancreatitis traditionally has involved early, aggressive surgical debridement. A more recent study, however, showed that a conservative approach to therapy also is effective.2 Infected necrosis requires broad spectrum IV antibiotics followed by prolonged oral therapy, with many reports noting meropenem(Drug information on meropenem) followed by moxifloxacin(Drug information on moxifloxacin) for up to 2 months. For patients who require surgical intervention, postponement of surgical debridement for up to 1 month is recommended to allow demarcation and organization of the inflammatory mass.2,4,10 The absolute indication for necrosectomy in an infected pancreatic inflammatory mass is still evolving. A recent study found that up to one third of patients with infected necrosis can be treated with catheter drainage in conjunction with antibiotics.2
For emphysematous pancreatitis, there are no clear management protocols. In patients with hemodynamic and/or systemic compromise, a combination of aggressive management including IV antibiotics, ICU monitoring, and surgical consideration is recommended. Recommendations are less clear, however, in clinically stable cases where the underlying etiology can remain unclear.
In the case presented here, the finding of a penetrating duodenal ulcer provided a possible cause for the presence of air in the pancreas. This finding is similar to that seen in approximately half of patients in a small case series reported in 2009.3 We believe that in clinically stable patients with emphysematous pancreatitis, an EGD should be performed for further evaluation. In those without clinical or laboratory evidence of infection, we recommend limiting the use of broad spectrum antibiotics and instead propose conservative supportive care.