University of California San Francisco Fresno Fresno, CA
Sunny Sandhu, MD1, Dhuha Alhankawi, MD1, Jayakrishna Chintanaboina, MD, MPH1, Devang Prajapati, MD2; 1University of California San Francisco Fresno, Fresno, CA; 2University of California San Francisco Fresno / Vetarans Affairs Central California Health System, Fresno, CA
Introduction: Emphysematous pancreatitis (EP) is an extremely rare and life-threatening variant of severe acute pancreatitis, and has only been described in isolated case reports. Infection of pancreatic necrosis with gas-forming bacteria leads to gas in and around the pancreas. It is commonly due to Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We report a case of a patient who presented with suspected bowel perforation, and was subsequently found to have emphysematous pancreatitis.
Methods: A 73 year old male with a history of alcohol abuse presented with 5 days of epigastric pain and fevers. He reported drinking 80oz of beer daily. In the ED, vitals: T 103 F, BP 88/56, HR 118, RR 20. Exam showed epigastric tenderness. Labs showed WBC 12x109/L (5% bands), ALT 97 U/L, AST 179 U/L, ALP 120 U/L, total bilirubin 8.6 mg/dL and lipase 901 IU/L. CT showed marked intra and extrahepatic biliary dilation with extensive retroperitoneal gas-containing fluid surrounding the pancreatic bed concerning for bowel perforation. CT with oral gastrografin failed to show perforation. Given significant biliary dilation, he underwent urgent ERCP which showed distal CBD stricture with proximal CBD and intrahepatic biliary dilation. A biliary stent was placed with downtrend of liver enzymes. Distal CBD biopsies were benign. Due to worsening sepsis, a retroperitoneal drain was placed into the peripancreatic fluid collection with purulent drainage. Both drain and blood cultures grew Klebsiella pneumoniae. He improved with IV antibiotics, and was discharged. He presented 3 weeks later with dislodgement of the percutaneous drain, and an EUS-guided cyst gastrostomy stent was placed. Discussion: Emphysematous pancreatitis is rare, and has a mortality rate of up to 40%. CT is typically diagnostic, however findings of peripancreatic fluid and gas collections can be mistaken with common pathologies such as bowel perforation. Alcohol use accounts for 54% of reported cases. Our patient likely developed severe acute pancreatitis due to significant alcohol use, complicated by development of EP. The finding of distal CBD stricture and biliary dilation on ERCP was likely related to extrinsic compression from peripancreatic fluid collection. Guidelines for treatment of EP are limited. Approach ranges from conservative with IV antibiotics to percutaneous drainage and surgical necrosectomy. Early and prompt treatment is crucial, and requires individualized treatment with multidisciplinary team involvement.