Emphysematous Pancreatitis: A Rare Complication of Acute Nec
Emphysematous or gangrenous pancreatitis is a rare and fatal complication of acute necrotizing pancreatitis. It is characterized by the presence of gas in the necrotic pancreatic parenchyma and/or in peripancreatic collections. Abdominal CT is the examination modality of choice with high sensitivity and specificity for gas detection, collection and vascular pedicle abnormality detection, as well as other complications associated with acute pancreatitis. It allows for suspicion of emphysematous pancreatitis based on the intra- and/or peripancreatic presence of air, in a context of epigastric pain with elevated lipasaemia, 3 times higher than the normal value. However, gas is only observed in a minority of proven infections . The absence of gas does not exclude a diagnosis of secondary infection of acute necrotizing pancreatitis. Therefore, confirmation of the diagnosis is by percutaneous puncture of a peripancreatic collection in the context of a worsening clinical state despite adequate treatment.

A 61-year-old female patient with no specific medical history presented to the emergency department of University Hospital Centre Ibn Rochd of Casablanca for sudden-onset epigastric pain radiating to the back for 2 days, associated with nausea and vomiting. On examination, her temperature was 36.5°C, blood pressure was 120/70 mmHg, heart rate was 96 beats per minute and the respiratory rate was 16 cycles per minute. The patient had epigastric and right hypochondrium tenderness. The rest of the examination was unremarkable. Blood tests showed hyperleucocytosis of 18,680.103 cells/μl of blood, C-reactive protein (CRP) levels of 185.4 mg/l, lipasaemia of 450 IU/l and creatinine levels of 16 mg/l. The diagnosis retained was acute pancreatitis.After 4 days of hospitalization, the patient developed a fever of 39°C, with a deterioration in clinical condition. Abdominal CT was requested and showed a pancreatic corporocephalic necrosis of more than 50%, the presence of air bubbles (Fig. 1), several peripancreatic collections (Fig. 2), right colonic parietal thickening (Fig. 3) and peritoneal effusion and thrombosis of the superior mesenteric vein extending to the portal trunk .
Percutaneous puncture of a peripancreatic collection for bacteriological analysis was positive for Escherichia coli as a pathogenic agent, which was multi sensitive to antibiotics. The clinical and biological evolution of our patient was favorable under antibiotic treatment. She was discharged after 15 days of hospitalization.

In conclusion emphysematous pancreatitis results from a superinfection of an acute necrotizing pancreatitis, occurring most often in immunocompromised patients. Abdominal CT is the examination modality of choice for suspicion of emphysematous pancreatitis, which is indicated by the presence of intra- or peripancreatic gas in an evocative clinical and biological context. The diagnosis is confirmed by isolation of the pathogen in the peripancreatic aspiration fluid. However, mortality remains at a high level despite adequate treatment, occurring usually in a sepsis context with multiorgan failure.

Source: https://www.ejcrim.com/index.php/EJCRIM/article/view/1550