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Necrotizing Pancreatitis

Pancreatitis is inflammation (swelling) of the pancreas. In severe cases, this inflammation can cause tissue to die (necrotize). Necrotizing pancreatitis occurs in up to 20% of cases of pancreatitis. Infection, organ failure and severe complications can occur in some cases. It can lead to death if not treated.

Types of Necrotizing Pancreatitis

There are three types of necrotizing pancreatitis:

1. Parenchymal necrosis: Death of the pancreatic tissue itself
2. Peripancreatic necrosis: Death of the tissues surrounding the pancreas
3. Combined necrosis: Death of both the pancreatic tissue and the surrounding tissues

Combined necrosis is the most common type. The location of necrosis is the only thing that differs between the types of necrotizing pancreatitis. Causes, symptoms, diagnosis and treatment are the same for all three types.

What Causes Necrotizing Pancreatitis?

Acute pancreatitis causes necrotizing pancreatitis. There are many causes of pancreatitis. These include:

• Genetic mutations
• Gallstone pancreatitis
• Autoimmune disorders, such as autoimmune pancreatitis
• High levels of cholesterol and triglycerides
• Pancreatic trauma
• Damage to the pancreas from certain types of medicine, such as chemotherapy
• Alcohol abuse

When the pancreas is inflamed or injured, it can leak enzymes, which can damage its tissues. This damage can cause the tissue to die.

What are the Signs and Symptoms of Necrotizing Pancreatitis?

The symptoms of necrotizing pancreatitis are the same as the signs of acute pancreatitis. They include:

• Belly pain
• Nausea and vomiting
• Inability to eat
• Bloating
• Fever
• Fast heart rate
• Lightheadedness or dizziness, which can indicate low blood pressure
• Extreme thirst, dry mouth or dark pee, which can indicate dehydration

How is Necrotizing Pancreatitis Diagnosed?

It takes a few days from the beginning of acute pancreatitis for signs of necrosis (tissue death) to appear. To diagnose acute pancreatitis, doctors may do a blood test to check the levels of pancreatic enzymes and triglycerides.

To diagnose necrotizing pancreatitis, doctors also usually do imaging tests to see if the pancreas tissue, or tissue around it, is dead. These tests may include:

• Abdominal ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)

How is Necrotizing Pancreatitis Treated?

Doctors typically treat necrotizing pancreatitis conservatively at first. They provide supportive care, which includes intravenous (IV) fluids, pain medicine and rest.

The diet for necrotizing pancreatitis may be eaten by mouth or given through a nasogastric tube (NG) from the nose to the stomach, depending on symptoms. Or a nasojejunal feeding from the nose to the small intestine may be used for nutrition. As the patient heals, they will return to eating regular food.

If the patient has no symptoms and is doing well, no other treatment usually is needed.

Necrotizing Pancreatitis Complications

About four weeks after the start of pancreatitis, patients with necrotizing pancreatitis can develop pancreatic walled-off necrosis (WON). This is a collection of fluid and dead tissue that is contained within or near the pancreas by a wall of tissue. It can cause belly pain, a swollen belly, fever and nausea, or it may not cause symptoms.

Infections develop in 20%-30% of necrotizing pancreatitis cases, including WON. If an infection occurs, doctors prescribe an antibiotic.

One of the rare necrotizing pancreatitis complications is hemorrhagic necrotizing pancreatitis. This is where inflammation in the pancreas damages an artery or vein wall and causes bleeding. It can be life-threatening. Symptoms include belly pain, a swollen belly, lightheadedness or dizziness, fever, chills, nausea and vomiting.

Necrotizing Pancreatitis Surgery

If the patient has an infection, complication, pain, difficulty eating or other issues, doctors will drain and sometimes remove the dead tissue. There are several ways to do this:

• Endoscopic US-guided cystogastrostomy: In this minimally invasive procedure, doctors pass a thin tube (endoscope) through the mouth to the stomach. They use tools on the tube to create an opening between the WON and stomach to drain the area. This is the most common approach. Sometimes, they need to remove the dead tissue as well. This is called endoscopic US-guided necrosectomy.
• Percutaneous drainage: Sometimes, doctors can’t use an endoscope because the necrotic tissue isn’t close enough to the stomach or isn’t easily accessible. They puncture the skin on the belly with a needle to drain the area.
• Open surgery: If minimally invasive procedures haven't worked, or in an emergency situation, doctors may do traditional surgery. They cut the belly to access the pancreas and remove the dead tissue.

With minimally invasive procedures, patients without complications typically may go home within a few days, depending on their symptoms. Patients who have open surgery or complications such as infection or organ failure need to stay in the hospital longer.

The length of time it takes to recover from necrotizing pancreatitis varies greatly based on the patient’s overall health, the severity of the condition and the presence of complications. Patients with severe complications can be in the hospital for several months

Necrotizing Pancreatitis Prognosis

With early diagnosis and treatment, most people recover from necrotizing pancreatitis. But if necrotizing pancreatitis affects 50% or more of the pancreas and the patient develops an infection or organ failure, it can cause death in rare instances.

Necrotizing pancreatitis can come back in people who have recurrent pancreatitis. Risk factors include:

• Genetic mutations
• Gallstones
• Having had acute pancreatitis before
• Alcohol abuse
• Smoking

Doctors will watch patients for recurrence and potential long-term consequences of necrotizing pancreatitis. These can include:

• Exocrine pancreatic insufficiency: The pancreas may stop producing enough digestive enzymes or hormones. This can lead to malnutrition or diabetes.
• Disconnected pancreatic duct syndrome: The pancreatic duct can disconnect from the pancreas or small intestine. This can cause chronic pancreatitis.

Ideally, children with necrotizing pancreatitis should get care at a pediatric hospital that has experienced specialists and multidisciplinary teams.