Abstract
According to the Atlanta classification, the most widely accepted clinically based classification system for acute pancreatitis, four pathologic entities of fluid collections and necrosis are recognized. Acute fluid collections occur early as an exudative reaction to the pancreatic inflammation, have no fibrous wall, and resolve spontaneously. Pancreatic necrosis, the most severe form of acute pancreatitis, is diagnosed on dynamic contrast-enhanced computerized tomography and requires early aggressive cardiorespiratory resuscitation, nutritional support, and appropriate systemic antibiotics to prevent superinfection. Development of infection (infected necrosis) is the indication for operative debridement, preferably as late in the course of the disease as possible. Acute pseudocysts are collections of pancreatic, enzyme-rich fluid caused by pancreatic ductal disruption that occur 3 to 6 weeks after onset of acute pancreatitis and have a well-defined, nonepithelial fibrous wall. If communication with the ductal system is present, internal enteric drainage (either operative or endoscopic) is more effective; if communication is not present, the pseudocysts are amenable to percutaneous drainage. A pancreatic abscess is an infected, circumscribed peripancreatic collection, associated with minimal or no parenchymal necrosis, that occurs late (4 to 6 weeks) after onset of severe pancreatitis and may represent an infected pseudocyst; percutaneous drainage is the treatment of choice.
Similar content being viewed by others
References and Recommended Reading
Bradley EL III: A clinically based classification system for acute pancreatitis. Arch Surg 1993, 128:586–590.
Yeo CJ, Sarr MG: Cystic and pseudocystic diseases of the pancreas. In: Curr Probl Surg 1994, 31:165–252.
Tsiotos GG, Luque-de Leon E, Söreide JA, et al.: Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique. Am J Surg 1998, 175:91–98. Includes critical analysis of the evolution of the various techniques of necrosectomy and management of the pancreatic bed. Also, the current understanding on the biphasic pattern of mortality and use of antibiotics is presented.
Renner IG, Savage WT, Pantoja JL, et al.: Death due to acute pancreatitis: a retrospective analysis of 405 autopsy cases. Dig Dis Sci 1985, 30:1005–1018.
Widdison AL, Karanja ND: Pancreatic infection complicating acute pancreatitis. Br J Surg 1993, 80:148–154.
Pederzoli P, Bassi C, Vessentini S, Campedelli A: A randomized multicentre clinical study of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 1993, 176:480–483.
Luiten EJT, Hop WCH, Lange JF, Bruining HA: Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 1995, 222:57–65.
Delcenserie R, Yzet T, Ducrois JP: Prophylactic antibodies in treatment of severe acute alcoholic pancreatitis. Pancreas 1996, 13:198–201.
Grewe M, Luque-de Leon E, Tsiotos GG, Sarr MG: Fungal infection in acute necrotizing pancreatitis. J Am Col Surg, in press.
Kingsnorth AN, Galloway SW, Formela LJ: Randomized, double-blind phase II trial of Lexipafant, a platelet-activating factor antagonist, din human acute pancreatitis. Br J Surg 1995, 82:1414–1420.
Foitzik T, Bussi DG, Lewandrowski K, et al.: Intravenous contrast medium accentuates the severity of acute necrotizing pancreatitis in the rat. Gastroenterology 1994, 106:207–214.
Kaiser AM, Grady T, Gerdes D, et al.: Intravenous contrast medium does not increase the severity of acute necrotizing pancreatitis in the opossum. Dig Dis Sci 1995, 40:1547–1553.
Mier J, Luque-de Leon E, Castillo A, et al.: Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997, 173:71–75. Very well-designed and executed prospective randomized trial that demonstrated for the first time the beneficial results of late necrosectomy. This article provided the data for the change of practice in many pancreatic centers.
Fernandez-Del Castillo C, Rattner DW, Makary MA, et al.: Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998, 228:676–684
Murr MM, Tsiotos GG, Sarr MG: Operative management of necrotizing pancreatitis. In Problems in General Surgery, vol 13. Edited by Sarr, MG, Soper NJ. Philadelphia: Lippincott-Raven, 1996:131–136.
Beger HG, Buchler M, Bittner R, et al.: Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br J Surg 1988, 75:207–212.
Yeo CJ, Bastidas JA, Lynch-Nyhan A, et al.: The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet 1990, 170:411–417.
Vitas GJ, Sarr MG: Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992, 111:123–19.
Kozarek RA, Traverso LW. Endotherapy for chronic pancreatitis. Int J Pancreatol 1996; 19:93–102.
van Sonnenberg E, Stabile BE, Varney RR, Christensen RR: Percutaneous drainage of infected and non-infected pseudocysts. Radiology 1989; 170:757–762
Freeny PC: Computed tomography. In Surgery of the Pancreas, edn 1. Edited by Trede M, Carter DC. Edinburgh: Churchill Livingstone; 1993:61–72.
Palmer KR, Carter DC: Endoscopic retrograde cholangiopancreatography. In Surgery of the Pancreas, edn 2. Edinburgh: Churchill Livingstone, 1997:99–118.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Tsiotos, G.G., Sarr, M.G. Management of fluid collections and necrosis in acute pancreatitis. Curr Gastroenterol Rep 1, 139–144 (1999). https://doi.org/10.1007/s11894-996-0013-9
Issue Date:
DOI: https://doi.org/10.1007/s11894-996-0013-9