Pancreatic abscess
Synonyms and keywords: Abscess of pancreas
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# Overview
Pancreatic abscess is an unusual and rare, but life threatening complication of acute pancreatitis. It develop 5 weeks after the onset of pancreatitis and after onset of symptoms and subsidence of the acute phase of pancreatitis. Most of the pancreatic abscesses are developed from the progressive liquefaction of necrotic pancreatic and peri-pancreatic tissues, but some arise from infection of peri-pancreatic fluid or collections elsewhere in the peritoneal cavity. According to the Balthazar and Ranson's radiographic staging criteria, patients with a normal pancreas, an enlargement that is focal or diffuse, mild peri-pancreatic inflammations or a single collection of fluid (pseudocyst), have less than 2% chances of developing an abscess. However, the probability of developing an abscess increases to nearly 60% in patients with more than two pseudocysts and gas within the pancreas. Pancreatic abscess is the most dangerous complication and the most common cause of death for acute pancreatitis.

# Definition
Pancreatic abscess is defined as a localized collection of pus surrounded by a more or less distinct capsula in inflamed pancreas.

# Historical Perspective
- First case of pancreatic abscess is described by Carrick H. Robertson in 1908.
- Simple and safe method of surgical draining for pancreatic abscess described by Albert J. Ochsner in 1921.

# Pathophysiology
Pathogenesis of pancreatic abscesses is due to combination of ischemic necrosis and enzymatic injury to the pancreatic tissue by escaped pancreatic enzymes. Pancreatic abscess is commonly present in 1% to 30% of all patients with clinical acute pancreatitis, but it is more frequetly occurs in up to 50% to 70% of patients with severe necrotizing pancreatitis.

# Causes

## Common Causes
Common organisms causing pancreatic abscess are as follows:

# Differentiating Pancreatic Abscess from other Diseases
Pancreatic abscess should be diagnosed early and treat promptly not only to reduce morbidity and mortality, but also it is important to differentiate from other pancreatic diseases such as: recurrent pancreatitis and pancreatic pseudocysts as the undrained abscess carreies high risk of mortality.

# Epidemiology and Demographics

## Incidence
Incidence of pancreatic abscess is unknown, but McClave et al reported it as 2-5% among patients hospitalized for pancreatitis.

## Case Fatality Rate
Mortality rate of pancreatic abscess is varies depending upon the severity of pancreatitis with range of 10-59%.

## Age & Gender
No age and gender predilection for pancreatic abscess.

## Race
Pancreatic abscess has no race predilection.

# Risk Factors
Pancreatic abscess often co-exists with several risk factors, but the major one is the acute pancreatitis. Common risk factors of pancreatic abscess include:

# Natural History, Complications and Prognosis

## Complications

## Prognosis
Prognosis of pancreatic abscess depends on the time of diagnosis and treatment. Outcome of pancreatic abscess is generally based on the severity of the infection. It is however a severe complication which may result in the death of the patient if the appropriate treatment is not administered. Patients are at risk of sepsis and multiple organ failure and in patients with delay in surgery to remove infected abscess, the mortality rate can get to 100%.
Poor prognostic factors
- Delayed diagnosis
- Delayed surgical drainage
- Improper antibiotic use
- Alcohol addiction

# Diagnosis
As the clinical presentation of pancreatic abscess is variable or even obscure, it should be considered in any febrile patient even 2 weeks after an attack of acute pancreatitis, even in the absence of other symptoms. Most patients who develop pancreatic abscesses have had pancreatitis, so a complete medical history is required as a first step in diagnosing abscesses.

## History and Symptoms
Presenting symptoms of pancreatic abscess are vague and variable, but common symptoms include:

## Physical Examination Findings

## Appearance
Patient with pancreatic abscess appears ill and diaphoretic

## Vital signs
- High-grade fever (greater than 37.8C)
- Tachycardia
If patient present with sepsis:
- Hypotension
- Tachycardia
- Increased capillary refill time

## Heart
- No specific cardiovascular findings related to pancreatic abscess.

## Lungs
Left sided pleural effusion may be present with signs of:
- Decreased breath sounds on left side
- Dullness to percussion on left side
- Absent tactile fremitus on left side
- Friction rub over the left chest

## Abdomen
Palpation
- Abdominal tenderness
- Palpable abdominal mass
- Abdominal distention

## Lab Findings

### Blood Tests
- CBC with differential: Leukocytosis (range between 10,500 to 35,00O/mm3)
- Blood culture: Low sensitivity to diagnose causative organism in pancreatic abscess as shows positivity in few cases, but it helps to distinguish abscesses from sterile pseudocysts and provide guidance for selection of antibiotics.

## Fine Needle Aspiration
Advantages
- Fine needle aspiration can distinguish sterile inflammation from infection and it is the procedure of choice in the verification of bacterial infection.
- High sensitivity of 90% to 100%
- Low complication rate
- It aid in the early diagnosis of infectious complications of pancreatic abscess and to avoid unnecessary laparotomy.

## Imaging
Imaging studies are crucial in the diagnosis and treatment of pancreatic abscess. Both ultrasonography and computed tomography (CT) can be helpful with the diagnosis and localization of pancreatic abscesses, which may extend from the pancreas anywhere (e.g. retroperitoneum, mesentery, mediastinum, and even the neck or genitalia).

### X-ray
- Shows extraluminal (pancreas or lesser sac) gas bubbles suggesting abscess
- Disclosed pleural effusion
- Diaphragmatic elevation
- Basilar atelectasis

### Ultrasound
- Shows fluid filled sac suggesting abscess

### CT
CT had a sensitivity of 74%, compared with 35% for ultrasound in the diagnosis of pancreatic abscess.
CT of Pancreatic abscess
CT of Pancreatic psuedocyst

# Treatment

## Medical Therapy
Antibiotics are commonly used as a curing method for pancreatic abscesses although their role remains controversial. Prophylactic antibiotics are normally chosen based on the type of flora and the degree of antibiotic penetration into the abscess. Pancreatic abscesses are more likely to host enteric organisms and pathogens such as E. coli, Klebsiella pneumonia, Enterococcus faecalis, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, and Streptococcus species. Medical therapy is usually given to people whose general health status does not allow surgery. On the other hand, antibiotics are not recommended in patients with pancreatitis, unless the presence of an infected abscess has been proved.

## Surgical Therapy
Surgical therapy is the traditional method of treatment of pancreatic abscesses, usually by inserting one or more non-traumatic drains through trans-peritoneal or through flank or retroperitoneum into the abscess cavity. Although there have been reported cases of patients who were given medical treatment and survived, primary drainage of the abscess is the main treatment used to cure this condition. Drainage usually involves a surgical procedure. It has been shown that CT-guided drainage brought inferior results than open drainage. Hence, open surgical procedure is preferred to successfully remove the abscess. However, CT-guided drainage is the option treatment for patients who may not tolerate an open procedure. Endoscopic treatment is at the same time a treatment option that increased in popularity over the last years. Failure of the surgical drainage might be due to the reluctance to expose the cavity widely and to debride the necrotic components aggressively. For a detailed approach on performing surgical drainage of pancreatic abscess watch the video below:

# Prevention
In some cases, abscesses may be prevented by draining an existing pseudocyst which is likely to become inflamed. However, in most cases the developing of abscesses cannot be prevented.