A 61-year-old obese man with newly diagnosed type 2 diabetes mellitus and hypertension presented to the emergency department with complaints of fatigue and poor oral intake. The patient also complained of a 10-lb weight loss that began approximately 2 weeks before admission but denied any significant abdominal pain, nausea, vomiting, steatorrhea, scleral icterus, and jaundice. He had no prior GI history, including a negative history of pancreatitis. He denied alcohol abuse but admitted to prior marijuana use.
The physical examination was unremarkable except for a blood pressure of 80/60 mm Hg, which corrected with infusion of 2 L of normal saline. Laboratory findings included normal values for a complete blood cell count, complete metabolic panel, and serum amylase/lipase. CT of the abdomen and magnetic resonance cholangiopancreatography revealed acute emphysematous pancreatitis with extensive pancreatic necrosis (> 60%), without evidence of gallbladder or biliary tract disease (Figures 1 and 2).
The patient was aggressively managed with IV fluids and IV imipenem and was monitored in the ICU. He remained clinically stable and after 2 days was downgraded to a regular ward, taken off antibiotic therapy, and clinically monitored. A subsequent esophagogastroduodenoscopy (EGD) revealed a posterior wall penetrating duodenal ulcer >2 cm in diameter (Figure 3). The patient remained asymptomatic throughout his hospital course, without evidence of clinical or hemodynamic compromise. He was able to tolerate oral intake within 2 days of admission. He was discharged in stable condition with plans to complete high-dose PPI therapy. He has remained stable and emphysematous pancreatitis has resolved (Figure 4).
Necrotizing pancreatitis, a severe form of pancreatitis, occurs in up to 20% of patients who have acute pancreatitis.1 At least 30% of the pancreas must show necrosis on CT for a definitive diagnosis. Approximately 30% of patients with necrotizing pancreatitis develop infected necrosis. Mortality rates among these patients ranges from 20% to 40%.2-5 Emphysematous pancreatitis is a rare form of necrotizing pancreatitis. It is characterized by free air within the lesser sac or pancreatic parenchyma, the source of which is typically attributed to infection as opposed to an enteropancreatic fistula.6 Infectious causes are secondary to gas-forming organisms, most commonly polymicrobial infections, including anaerobes and gram-negative bacteria.3-5 Underlying etiologies for enteropancreatic fistulas are numerous. When associated with pancreatitis, however, the most common causes are believed to be complications of pancreatic inflammatory masses secondary to acute pancreatitis or pancreatic pseudocyst drainage.3-5,7
Historically, emphysematous pancreatitis has been managed with broad-spectrum antibiotics and early surgical debridement. Recently, however, case reports/series have shown that patients without evidence of hemodynamic or other systemic compromise have been successfully managed with conservative therapy.2-4
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