Pankreatitis

A 78-year-old man had fever, intermittent nausea and vomiting, and increasing abdominal pain for one week. He said he did not use alcohol. On examination, he had a distended abdomen and marked epigastric tenderness. His serum amylase and lipase levels were 1485 and 1608 U per liter, respectively. A contrast-enhanced computed tomographic (CT) scan of the abdomen showed a large amount of gas that severely distorted the pancreatic parenchyma (arrow) and a distended gallbladder with a 2-cm stone in its neck (arrowhead). The patient was treated with bowel rest, fluids, and imipenem. A CT scan one week later showed increasing emphysematous changes in the pancreas, with fluid replacing the pancreatic parenchyma. A percutaneous catheter was inserted, and Escherichia coli was isolated. The patient subsequently underwent pancreatic necrosectomy and cholecystectomy and was discharged three weeks after surgery. Emphysematous pancreatitis is a severe complication of acute pancreatitis. It is diagnosed on clinical grounds and on the basis of the radiologic finding of gas in the retroperitoneum. Retroperitoneal gas in a patient who has clinical evidence of pancreatitis warrants early use of antibiotics, percutaneous drainage of the fluid collection, and (if there is no clinical response to those measures) surgical resection of the infected necrotic tissue.