Fulminant Emphysematous Pancreatitis: Diagnosis Time Counts

Abstract

Emphysematous pancreatitis (EP), a severe form of necrotizing infection of the pancreas, is an extremely rare medical emergency with high rates of mortality. It is characterized by intraparenchymal pancreatic or peri-pancreatic air due to either monomicrobial or polymicrobial infection with gas-forming bacteria or due to entero-pancreatic fistula. EP is classified according to timing from disease onset when air bubble signs were detected on computed tomography (CT) scan, as early onset (within 2 weeks from disease onset) or late (more than 2 weeks from disease onset). While most cases of acute pancreatitis are resolved with supportive care alone, clinical outcomes of EP, especially the early onset subtype, are very poor with high rates of morbidity and mortality. These two case reports present the clinical features, diagnostic investigations, and management of two patients admitted to our hospital with early onset fulminant EP, each investigated and managed with different approaches. The first patient underwent a more conservative treatment, with diagnosis being made 52 h following admission, and thus, intensive care unit (ICU) admission and surgery were postponed, while the second patient was diagnosed a few hours following presentation with earlier ICU admission. In this article, we will present the critical importance of early diagnosis of the aforementioned rare entity of severe pancreatitis and will consider the consequences of rapid diagnosis on disease course, morbidity and mortality.