A Case of Spontaneous Intraperitoneal Rupture of an Acute Necrotic Fluid Collection Associated with Necrotizing Pancreatitis

Abstract

Patient: Male, 61 Final Diagnosis: Intraperitoneal rupture of acute necrotic peri-pancreatic fluid collection Symptoms: Abdominal and/or epigastric pain • abdominal distension • hypotension • shock Medication: — Clinical Procedure: Exploratory laparotomy with external pancreatic drainage • exploratory laparotomy, cholecystectomy, cystgastrostomy Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: An acute necrotic fluid collection is a rare condition that occurs within four weeks of the onset of necrotizing pancreatitis. This report is of a case of spontaneous intraperitoneal rupture of an acute necrotic fluid collection that required emergency laparotomy. Case Report: A 61-year-old man presented with worsening symptoms following hospital discharge for necrotizing pancreatitis. On hospital admission, a computed tomography (CT) scan showed changes of pancreatic necrosis and inflammation with a peripancreatic fluid collection. On the sixth day following admission, he developed hemodynamic instability and peritonitis. Repeat CT scan showed a reduction in the size of the peripancreatic collection but free intraperitoneal fluid, consistent with intraperitoneal rupture. At exploratory laparotomy, several liters of necrotic pancreatic fluid were drained from the abdomen, followed by admission to the intensive care unit (ICU) for continued resuscitation. On postoperative day 3, he underwent open cystgastrostomy, cholecystectomy, placement of a jejunostomy tube (J-tube), and abdominal closure. He remained in the ICU for several weeks until ventilatory support could be reduced, and was transferred to the hospital ward when he was able to tolerate J-tube and oral feeding. On postoperative day 35, he was transferred to a long-term care facility. Conclusions: Acute pancreatitis is usually managed conservatively, and surgical management has become less common. A case of acute necrotic fluid collection arising within the first four weeks of onset of acute necrotizing pancreatitis is presented that underwent spontaneous intraperitoneal rupture leading to ascites, peritonitis, and hemodynamic instability, requiring emergency surgical management.

Spontaneous Peritoneal Rupture of a Large Pancreatic Pseudocyst in a Critically Ill Patient

“…A review of the literature has shown less than 10 documented cases. 2,[4][5][6][7][8][9] As expected, ruptured PP releases enzymatic fluid that immediately causes chemical peritonitis. In multiple case reports, patients presented with abdominal pain, hemodynamic instability, and death.…”

“…The goals are (1) to remove pancreatic ascites thus preventing complications such as peritonitis and (2) to close pancreatico-peritoneal leak, thus preventing continued ascites accumulation within the peritoneal cavity. In multiple case reports, immediate exploratory laparotomy was followed by abdominal washout and internal drainage via cystgastrostomy or cystojejunostomy 2,8 …”

Spontaneous Free Peritoneal Perforation of an Infected Pancreatic Fluid Collection Managed with Laparoscopic Drainage and Necrosectomy

“…PubMed search revealed 5 cases of spontaneous free peritoneal perforation of PFC. Rocha et al in 2016 presented two patients while Hui et al presented one patient in 2019 [17,18]. All these patients underwent exploratory laparotomy to control sepsis.…”

Inguinal and Perineal Necrotizing Fasciitis, A Rare Clinical Manifestation of Necrotizing Pancreatitis: Two Case Reports

“…Severe necrotizing pancreatitis has a 20% and 40% mortality rate in patients with sterile necrosis and infected necrosis with multi-organ failure, respectively [6]. Acute pancreatitis etiologies include gallstones, alcohol consumption, trauma, and some medications [7]. Hyperlipidemia is another cause of acute pancreatitis in approximately 10% of cases [8].…”

“…In most cases, acute peripancreatic fluid collection and acute necrotic fluid collection resolve with conservative management. Surgical intervention is reserved for complications such as hemorrhage, rupture, infection, and fistula formation [7] to abscess formation. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are caused mostly by trauma or perforated visceral organs; however, they are rarely caused by infected retroperitoneal collections.…”