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ISSN: 1734-1922
Archives of Medical Science
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vol. 16
Letter to the Editor

Successful endoscopic treatment of walled-off pancreatic necrosis complicated with pancreaticopleural and pancreaticocolonic fistulas

Mateusz Jagielski
Marian Smoczyński
Anna Jabłońska
Joanna Pieńkowska
Krystian Adrych
Marek Jackowski

Arch Med Sci 2020; 16 (2): 471–474
Online publish date: 2020/02/04
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A 53-year-old man was admitted to a different medical center due to abdominal pain with nausea in December 2015. Severe acute pancreatitis of alcoholic etiology was recognized. Conservative treatment was applied. Acute necrotizing pancreatitis was discovered in imaging examinations (Figure 1 A). The computed tomography severity index (CTSI) showed 8 points. Gradual liquidation and encapsulation of necrosis of the pancreatic tail and peripancreatic tissues (with no features of infection) were confirmed in subsequent imaging examinations, which were done in the next days of hospitalization. The patient was released home after 3 weeks of hospitalization. Later on the same patient was admitted to our department in January 2016 with a 1-week history of abdominal pain, fever, dyspnea and diarrhea. The laboratory blood tests done after admission revealed increased parameters of inflammation (CRP 263 mg/l; leukocytosis 22 G/l). Blood cultures were negative. Contrast-enhanced computed tomography (CECT) showed walled-off pancreatic necrosis (WOPN) and left sided pleural effusion (Figure 1 B). The infected WOPN was recognized in the described case. Empirical antibiotic therapy (tazobactam with piperacillin) was applied on the first day of hospitalization. The patient was qualified for endoscopic treatment of WOPN on the basis of clinical symptoms related to the presence of necrotic collection and the results of CECT of the abdomen. Endoscopic transmural drainage was not possible (the distance between the gastrointestinal tract and WOPN exceeded 15 mm in endoscopic ultrasonography imaging); therefore active transpapillary drainage was started via the major duodenal papilla (Figure 1 C). A fluid sample from the collection was taken for microbial culture during the endoscopic procedure. Positive culture of the collection’s content confirmed the presence of Enterococcus faecalis, Enterococcus faecium and Escherichia coli. The antibiotic therapy, applied previously, was continued for the next 44 days in accordance with culture of the collection’s content. Therapeutic thoracentesis was also performed. Laboratory analysis of the pleural fluid showed increased concentration of amylase (2346 U/l) and low protein concentration (below 3 g/dl). After 7 days of treatment contrast injected via a nasal drain filled the necrotic collection with contrast leak into the left pleural cavity (Figure 1 D) and colon (Figure 1 E). CECT showed disruption of the diaphragm...

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