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- Sterile or infected pancreatic necrosis—necrosis may become secondarily infected in 40-60% of pts, typically within 1-2 weeks after the onset of pancreatitis. Percutaneous aspiration of necrosis with Gram stain and culture should be performed if there are ongoing signs of possible pancreatic infection such as sustained leukocytosis, fever, or organ failure. Repeated fine-needle aspiration and Gram stain with culture of pancreatic necrosis may be done every 5-7 days in the presence of persistent fever. Repeated CT or MRI imaging should also be considered with any change in clinical course to monitor for complications. Sterile necrosis is most often managed conservatively unless complications arise. Once a diagnosis of infected necrosis is established and an organism identified, targeted antibiotics should be instituted. Pancreatic debridement (necrosectomy) should be considered for definitive management of infected necrosis, but clinical decisions are generally influenced by response to antibiotic treatment and overall clinical condition. A step-up approach (percutaneous or endoscopic transgastric drainage followed, if necessary, by open necrosectomy) has been successfully reported by some pancreatic centers.
- Pancreatic pseudocysts develop over 1-4 weeks in 15% of pts. Abdominal pain is the usual complaint, and a tender upper abdominal mass may be present. Can be detected by abdominal ultrasound or CT. In pts who are stable and uncomplicated, treatment is supportive; pseudocysts that are >5 cm in diameter and persist for >6 weeks should be considered for drainage. In pts with an expanding pseudocyst or one complicated by hemorrhage, rupture, or abscess, surgery should be performed.
- Pancreatic ascites and pancreatic duct disruption. Diagnosis can be confirmed on MRCP or ERCP. Placement of a bridging pancreatic stent for at least 6 weeks is >90% effective at resolving the leak.
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