Necrotizing Pancreatitis

What is necrotizing pancreatitis?

Necrotizing pancreatitis is a complication of acute pancreatitis in which part of your pancreas dies. This can happen when pancreatitis is very severe. Pancreatitis is inflammation and swelling in your pancreas, usually in response to an injury or toxins. Severe inflammation can stop the blood flow to your pancreas tissues (ischemia), causing tissue death (necrosis). This is a serious development.

Your healthcare team will need to keep you in the hospital for a while to watch out for further complications that can develop. The most urgent of these is infection. If bacteria come to feast on the dead tissue, they could quickly multiply and spread through your body. This could lead to organ failure and even death. In this event, your healthcare team will likely need to remove the dead tissue.

How common is necrotizing pancreatitis?

Necrotizing pancreatitis occurs in approximately 20% of acute pancreatitis cases. In the U.S., acute pancreatitis leads to about 275,000 hospital stays each year.

What does necrotizing pancreatitis feel like?

The first symptoms of necrotizing pancreatitis are those of acute pancreatitis, including:

• Upper abdominal pain, usually severe. It might radiate to your back.
• Abdominal distension or bloating.
• Nausea and vomiting.

As pancreatitis becomes more severe, you might develop:

• Fever and chills.
• Tachycardia (fast heart rate).
• Severe thirst or dehydration.

What causes necrotizing pancreatitis?

The causes of necrotizing pancreatitis happen in stages. It begins with acute pancreatitis that becomes severe, then ischemia sets in, and finally, necrosis develops. Each of these events has its own causes.

Pancreatitis becomes severe.

The most common cause of severe acute pancreatitis is gallstone disease when a gallstone obstructs your pancreatic duct. This is also called gallstone pancreatitis. The second leading cause is alcohol use.

Inflammation is your body’s response to injury and an attempt to repair the damage. But sometimes the inflammatory response is so severe, it does its own damage.

It’s not always clear why some people have a stronger inflammatory response than others. But it’s clear that this has a snowball effect within your pancreas.

Severe inflammation creates so much pressure that it activates the pancreatic enzymes within your pancreas tissues. These digestive enzymes are usually inactive until they reach your digestive system. When they activate, they begin to digest your pancreas.

Ischemia leads to necrosis.

This ongoing injury to your pancreas continues to escalate pancreatitis. Eventually, swelling in your pancreas compresses the blood vessels, reducing blood supply to the tissues.

Another possible contributing factor is systemic inflammatory response syndrome (SIRS). This is a whole-body inflammatory response that can cause an overall drop in blood pressure and blood flow.

Lack of blood flow (ischemia) causes tissue death (necrosis). Digestion by pancreatic enzymes probably also contributes to necrosis.

What are the possible complications of necrotizing pancreatitis?

Short-term complications of necrotizing pancreatitis may include:

• Infection. Infection is the most significant risk with necrotizing pancreatitis, occurring in up to 20% of cases. Dead tissues are a feast for roaming bacteria, and an infection when you’re already ill is harder to contain. If it spreads to your bloodstream, it could be life-threatening. An infection in your bloodstream (septicemia) can trigger sepsis, which can progress to multiple organ failure. This is the leading cause of death in people with necrotizing pancreatitis.
• Necrotic fluid collections. Severe pancreatitis can cause activated pancreatic enzymes to leak from your pancreas and irritate the surrounding tissues. A capsule of thin tissue develops around the pancreatic fluid. If the capsule also contains necrotic tissue, and if bacteria are trapped inside with it, an infection could start there and easily spread. Rarely, the capsule could also grow large enough to compress nearby organs, like your stomach, blood vessels or bile duct.
• Hemorrhage. Hemorrhagic pancreatitis is rare, but it’s life-threatening when it occurs. Necrotizing pancreatitis can make hemorrhage (bleeding) more likely. One way it can happen is if inflammation in your pancreas or a fluid collection spreads to a nearby artery. Inflammation against the artery wall may cause it to erode. Another way it can happen is if pancreatic enzymes erode an artery wall. This produces a pseudoaneurysm, which can rupture and bleed.
• Abdominal compartment syndrome. Swelling, bleeding and other fluid accumulations associated with necrotizing pancreatitis can build up within your abdominal cavity and create intense intra-abdominal pressure. This is a complication that mainly occurs in people who are critically ill. Abdominal compartment syndrome can reduce blood flow to your organs, leading to blood clots, ischemia and hypoxia (low oxygen perfusion). This can trigger multiple organ failure.

Long-term consequences of necrotizing pancreatitis may include:

• Pancreatic insufficiency. If you lose too much of your pancreatic tissue, your pancreas might lose some of its functionality. Exocrine pancreatic insufficiency is when it stops producing enough digestive enzymes, which you need to break down nutrients. It can lead to malabsorption and malnutrition. Endocrine pancreatic insufficiency is when it stops producing enough of the hormones that regulate your blood sugar. It can lead to hyperglycemia and diabetes.
• Disconnected pancreatic duct syndrome. Severe swelling, bleeding, necrosis, and other complications of necrotizing pancreatitis can partially disconnect the pancreatic duct from your pancreas or from your small intestine. This can cause chronic leaking of pancreatic enzymes. Leaking can lead to chronic fluid collections and/or chronic pancreatitis.
• Biliary stricture. Severe and sustained inflammation can cause scarring in any of the ducts that connect your pancreas to your digestive system. This includes your pancreatic duct, bile ducts and duodenum (the entry to your small intestine). Scarring leads to stricture, an abnormal narrowing of the duct that can slow the passage bile. This leads to bile backing up into your biliary system.
• Splanchnic vein thrombosis. Your splanchnic veins run along the underside of your pancreas, and severe pancreatitis can compress them. This can trigger thrombosis (blood clotting) in these veins. The splanchnic veins include your splenic vein, mesenteric vein, hepatic vein and portal vein. Thrombosis in one of them can cause various complications, including portal hypertension, gastrointestinal varices, gastrointestinal bleeding, ischemic colitis and mesenteric ischemia.

How is necrotizing pancreatitis diagnosed?

Healthcare providers diagnose necrotizing pancreatitis after diagnosing acute pancreatitis. It takes at least three to five days from the onset of pancreatitis for visible signs of necrosis to appear. If you have signs or symptoms of severe pancreatitis several days after the initial onset, your provider will look for necrosis on a contrast-enhanced CT scan (computed tomography scan) or MRI (magnetic resonance imaging). They’ll also look for other complications, like fluid collections.

What is the treatment for necrotizing pancreatitis?

Your treatment will depend on whether or not you develop an infection or other complications. When pancreatic necrosis is sterile and doesn’t cause symptoms, healthcare providers treat it conservatively with supportive care. When signs of infection or other complications develop, healthcare providers intervene as necessary. They’ll attempt to remove the necrotic tissue by minimally invasive methods before resorting to surgery.

Conservative management

Supportive care for sterile necrotizing pancreatitis includes:

• Pain relief.
• IV fluids.
• Enteral nutrition.

Most uncomplicated cases will resolve with supportive care alone. Your healthcare team will keep a close eye on your condition during this time. They’ll monitor your vital signs, your intra-abdominal pressure and your complete blood cell count (CBC) to watch for signs of possible complications. If infection or organ failure develops, they’ll offer life support or other interventions as necessary.

Drainage and debridement

When signs of infection appear, your healthcare team will immediately start you on antibiotics and then make plans to remove the necrotic tissue if they can. They’ll begin with the least invasive method possible and step up their methods as needed.

Methods include:

• Percutaneous drainage. Percutaneous means through the skin. An interventional radiologist uses radiology (usually ultrasound or CT) to locate the necrotic tissue and install a drainage tube through your skin to the site. They’ll leave the drain in place, irrigating with saline and draining it a few times a day. For up to a third of people, this is all that’s needed. For the rest, it helps to contain the infection until it’s safe to attempt debridement (tissue removal) by other methods.
• Endoscopic debridement. Endoscopy allows a gastroenterologist (a provider who treats gastrointestinal diseases) to access the necrotic site internally, without needing to cut through your skin. They’ll pass an endoscope equipped with an ultrasound probe through your upper GI tract to find the site on your pancreas. Then they’ll pass tools through the endoscope to create a channel between the necrotic site and your GI tract. They’ll remove the dead tissue through that channel.
• Video-assisted retroperitoneal debridement (VARD). This minimally invasive surgery method uses the percutaneous drainage portal you already have to access the necrotic site with surgical tools. A surgeon uses long forceps, irrigation and suction through the portal to remove the dead tissue. If necessary, they can insert a laparoscope, a tube with video camera attached, through the portal by widening it. Then they’ll remove the remaining tissue by laparoscopic surgery.
• Open surgery (necrosectomy). Necrosectomy means cutting out necrotic tissue. Open surgery means opening up your abdominal cavity (laparotomy) to locate the necrosis. This is still the most immediate way to find and fix urgent complications. While surgery comes with its own risks, it remains a last resort for emergencies and when less invasive methods haven’t worked.

What are the mortality and survival rates for necrotizing pancreatitis?

Survival rates differ depending on how much necrosis you have, whether you develop an infection or organ failure, and how you respond to treatment. If it affects less than 30% of your pancreas, mortality rates are less than 15%. The same is true if you have necrosis without any infection. If it affects more than 50% of your pancreas, or if you develop an infection or organ failure, mortality rates rise to over 30%.

What happens after treatment for necrotizing pancreatitis?

At your follow-up appointment, your healthcare provider will ask you about any continuing or new symptoms. Long-term complications can develop later after treatment for necrotizing pancreatitis. If you have symptoms, they might recommend labs or imaging tests to check on them. You might need additional treatment for complications, and the treatment might be short-term or long-term.

A note from Cleveland Clinic

Necrotizing pancreatitis is a serious escalation of acute pancreatitis. While most people recover from acute pancreatitis with only supportive care, those who develop severe pancreatitis and necrosis will need extended and intensive care. You’ll need a multitasking healthcare team to monitor your condition and possible complications. You might need interventions or surgery, and possibly follow-up care.