Pancreatic abscess is a cavity filled with pus and necrotic masses in the gland tissue. In the vast majority of cases, it develops after acute alcoholic pancreatitis. It is characterized by the appearance of fever, shingles, leukocytosis, tumor-like formation in the abdominal cavity about two weeks after an attack of pancreatitis. The diagnosis is established after ultrasound, MRI or CT of the abdominal cavity, analysis of biochemical and general clinical parameters of blood. The only effective method of treatment is surgical rehabilitation of the abscess followed by antibacterial therapy.
ICD 10
K85 Acute pancreatitis
General information
Pancreatic abscess is a serious disease that develops in patients who have suffered pancreatitis (acute or repeated exacerbation) or pancreatic necrosis with the formation of a delimited purulent cavity in the gland. The disease is dangerous for the patient’s life, and its insidiousness lies in the erasure of the clinic against the background of antibiotic therapy. That is why in modern gastroenterology it is customary to prescribe antibiotics for pancreatitis only with concomitant damage to the biliary tract or proven bacterial complications. All cases of fever and abdominal pain within two weeks after pancreatitis should be considered as a probable pancreatic abscess. The only method of treatment leading to recovery is surgical operation to drain the abscess. Without surgery, the mortality rate in this pathology reaches 100%.
Causes of pancreatic abscess
An abscess of the pancreas develops against the background of acute pancreatitis, can form in any form of pathology, except edematous; 3-4% of cases of this disease end in the formation of an abscess. It is most often detected against the background of alcoholic pancreatitis. The reasons for the formation of a purulent cavity in the pancreas are not completely clear. It is assumed that the infection can be introduced by blood flow, with a puncture of pseudocysts (if asepsis is not observed), with the formation of a fistula cyst with the intestine. The development of an abscess is promoted by:
- severe pancreatitis with more than three risk factors;
- postoperative pancreatitis;
- early laparotomy;
- early onset of enteral nutrition;
- irrational antibiotic therapy.
In the vast majority of cases, during aspiration and sowing of the contents of the abscess, Escherichia coli or enterobacteria are released. According to studies in the field of gastroenterology, the addition of a secondary infection is observed in almost 60% of cases of pancreatic necrosis, therefore, when treating this disease, the probability of formation of a cavity with purulent contents should be taken into account.
Pathogenesis
When acute pancreatitis occurs, the gland tissue is damaged, which causes enzymes to fall on the gland itself and on the surrounding tissues, destroying them. Because of this, pancreatic necrosis can begin, pseudocysts are formed – cavities filled with liquid contents and necrotic tissues. When an infection enters the area of the pathological process, either a pancreatic phlegmon develops – a total purulent melting, or an abscess forms. It should be noted that phlegmon is a more severe and prognostically unfavorable condition, which in the clinic practically does not differ from a single abscess. In addition, with phlegmon, multiple abscesses can form in the tissues.
Symptoms of pancreatic abscess
Pancreatic abscess is formed for a long time – usually at least 10-15 days. Thus, within two to four weeks from the onset of pancreatitis, the temperature rises to febrile figures, chills, tachycardia appear, pain in the upper half of the abdomen increases. The pains are of a shingling nature, quite strong. The patient pays attention to weakness, fatigue, lack of appetite, increased sweating. I am worried about nausea, vomiting, after which bitterness is felt in my mouth for a long time. There are all signs of intoxication. When palpating the abdomen, attention is drawn to the presence of a tumor-like formation, muscle tension of the anterior abdominal wall.
Complications
Pancreatic abscess is often complicated by the further spread of infection, the formation of multiple ulcers in the gland itself and surrounding organs. Pus can flow retroperitoneal, break through into hollow organs (intestines, stomach), subdiaphragmally and into the pericardial tissue, pleural and pericardial cavities, in connection with which an intestinal abscess, subdiaphragmatic abscess, purulent pleurisy and pericarditis can form. Also, the abscess can occasionally break out through the skin with the formation of a fistula. When enzymes destroy the vessel wall, severe bleeding may occur, sometimes with a fatal outcome.
Diagnostics
The diagnosis of pancreatic abscess is established by a specialist in the field of general surgery after a thorough examination of the patient. Differential diagnosis is carried out with pseudocyst of the pancreas, pancreatic necrosis. The following methods are used:
- Laboratory tests. In the general blood test, there is a high leukocytosis, a shift of the leukocyte formula to the left, an increase in ESR, anemia. In the biochemical analysis of blood, an increase in the level of pancreatic enzymes, hyperglycemia attracts attention. The level of urine amylase is increased, although its amount may gradually decrease during the formation of an abscess.
- Visualization techniques. Ultrasound of the pancreas, CT of the abdominal organs will allow you to determine the localization and size of the focus, the number of abscesses. If necessary, simultaneous percutaneous puncture with aspiration, examination and seeding of the contents is possible.
X-ray examination of pancreatic abscess has some features. Since the gland is located behind the stomach, the shadow of the abscess cavity can be superimposed on the gas bubble of the stomach. Therefore, the exposure should be longer, and if an abscess is suspected, a contrast agent is injected into the stomach cavity and a vertical picture is taken in a lateral projection – while a rounded shadow with a liquid border (abscess) will be located behind the stomach. If the contrast gets into the cavity of the abscess, we can talk about the presence of a fistula. Also in the pictures you can see signs of compression of the intestine, displacement of organs. The left diaphragmatic dome is high, its mobility is limited, there may be an effusion into the pleural cavity.
Treatment of pancreatic abscess
The treatment is carried out by an abdominal surgeon. An abscess is an absolute indication for sanitation and drainage. Practice shows that percutaneous drainage of ulcers leads to healing only in 40% of cases, besides, with such tactics, you can skip phlegmon, multiple abscesses, and the spread of infection to the surrounding pancreas tissues. That is why endoscopic or classical laparotomic excision and drainage of the abscess will be the best solution.
During the operation, a careful examination of the surrounding organs, retroperitoneal tissue for secondary abscesses is performed. In parallel, the patient is prescribed antibiotic therapy according to the received crops, painkillers, antispasmodics, enzyme inhibitors. Infusion therapy is carried out for the purpose of detoxification.
Prognosis and prevention
Since the causes of the formation of pancreatic abscesses have not been fully elucidated, to date there are no measures to prevent the development of this pathology after pancreatitis and pancreonecrosis. Thus, the prevention of abscess formation is the prevention of pancreatitis – after all, an abscess can form only against its background.
The prognosis for the formation of abscesses is serious: without surgical treatment, mortality is 100%, after surgery, survival reaches 40-60%. The outcome of the disease depends on the timeliness of treatment, rapid diagnosis and surgical treatment. The earlier the diagnosis is made and the operation is performed, the better the long-term results.
