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Pancreatic abscess
Pancreatic Abscess
Calvin E. Jones, MD, Louisville, Kentucky Hiram C. Polk, Jr, MD, Louisville, Kentucky Robert L. Fulton, MD, Louisville, Kentucky
Pancreatic abscess is an infrequent but potentially lethal infection described as a complication of acute pancreatitis [I 1. With rare exceptions [2], it is uniformly fatal if untreated [3]. The diagnosis is often obscured and delayed by a perplexing clinical presentation. Treatment may be compromised by frequent and multiple complications. Reported mortality after surgical drainage approximates 34 per cent [4]. A review of the experience at the Louisville General Hospital was accomplished to further delineate the clinical course of pancreatic abscess and assess the results of surgical treatment. Clinical Review Thirteen patients with pancreatic abscess were encountered at the Louisville General Hospital during the twenty year period ending January 1974. This represents an approximate incidence of pancreatic abscess of 3 per cent among patients hospitalized for acute pancreatitis during the same interval. The classic presentation of successfully treated acute pancreatitis followed in several weeks by recrudescence of symptoms and onset of a septic course was present in only one patient, although acute pancreatitis was found in all thirteen patients at operation or autopsy. From the Department of Surgery. University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky. Reprint requests should be addressed to Dr Calvin E. Jones, Department of Surgery, University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky 40201. Presented at the Fifteenth Annual Meeting of the Society for Surgery of the Alimentary Tract, San Francisco, California, May 21 and 22, 1974.
44
This series was comprised of ten men and three women with an age range of twenty-four to sixty-four years, the average being forty-one years. Biliary tract disease was present in five patients, chronic alcoholism in three, blunt pancreatic trauma in two, and penetrating pancreatic trauma in three. The diagnosis of pancreatic abscess was made preoperatively or at laparotomy in nine patients and at autopsy in the remaining four. Nausea, vomiting, and epigastric abdominal pain radiating to the back were the principal symptoms with fever, abdominal distention, and tenderness being the most common physical findings. (Figure 1.) A tender mass was palpable in only three patients. Pulmonary abnormalities, including left lower lobe pneumonitis, atelectasis, and pleural effusion, were present in eight patients. In general, signs and symptoms tended to be vague and nonspecific. Serum amylase determinations were obtained in all patients. Hyperamylasemia was present in six patients, returning to normal after surgical drainage in five. The sixth patient, in whom the diagnosis was made at autopsy, had an elevated amylase level until death. White blood cell counts ranging from 15,000 to 30,000 per mm3 were a consistent finding in every case. Other laboratory parameters were not of value in the assessment of these patients. Roentgenograms were of significant preoperative diagnostic value in six patients, and retrospectively in two more. Routine abdominal x-ray examinations were obtained in eleven patients and gave abnormal results in three. In one patient, in addition to loculated retrogastric air, the distance between the stomach and transverse colon was increased and interspersed with myriads of small bubbles not dissimilar in appearance to
The American Journal of Surgery
Pancreatic
fecal matter. Extraluminal air in the left,upper quadrant was noted in ,one patient, and loculated, retrogastric air in the lesser sac with anterior displacement of the stomach was seen in another. Contrast studies were extremely helpful in six of the eight patients evaluated in this manner. Upper gastrointestinal series in four patients demonstrated flattening and anterior displacement of the stomach, retrogastric extraluminal air, or widening and effacement of the duo.??nal loop. Intravenous pyelography, showing blurred contour and lateral displacement of the left kidney with extrinsic compression on the collecting system, was diagnostically useful in one patient. Sinus tract injection documented pancreatic abscess in another patient. Barium enema and an intravenous pyelogram gave normal results in two additional patients subsequently found to have pancreatic abscess. With two exceptions, the eight uninjured patients presented initially with evidence of peritonitis and occult progressive sepsis. One presented with acute pancreatitis followed by peritonitis. Another had undergone pancreatic cystogastrostomy three weeks after an episode of acute pancreatitis. Multiple postoperative complications developed, and three weeks later pancreatic abscess was diagnosed and drained externally. In this patient, internal drainage was inappropriately applied to the treatment of an early lesser sac collection and certainly contributed to the patient’s subsequent clinical course and death. Of the remaining six patients presenting with peritonitis, one had undergone cholecystectomy and exploration of the common bile duct one month previously. Another abscess occurred one year after cystoduodenostomy for pseudocyst of the head of the pancreas. The remaining four patients had no recent antecedent history of pancreatitis. Pancreatic abscesses after pancreatic trauma were encountered in five patients. One patient with a small caliber gunshot wound to the stomach and contusion of the tail of the pancreas was discharged asymptomatic one week after laparotomy with normal laboratory parameters and roentgenographic findings. He was readmitted the following week with signs of peritonitis, fixed left hemidiaphragm, and left pleural effusion. Pancreatic abscess was diagnosed at laparotomy. Another patient’s condition had improved significantly after a gunshot wound to the head of the pancreas until the tenth postoperative day when signs of sepsis and hemorrhage from the drain site occurred. Sinus tract injection demonstrated a pancreatic abscess. The remaining three patients with blunt (two) and penetrating (one) pancreatic trauma became septic during the first week after emergency laparotomy and had progressive multiple system organ failure and death with untreated pancreatic abscess. Nine patients were treated and eight survived. External drainage was employed in eight and internal gastric drainage in one. The interval between hospital admission and successful diagnosis and drainage averaged six days in the survivors. One patient in whom the diagnosis
Votume129.Januan1975
Abscess
Figure 1. Symptoms and physlcal findings are vague and nonspecific. was delayed three weeks died after external drainage. Four patients were not treated, and none survived. Preoperative assessment was correct in four patients. The remaining five underwent exploratory laparotomy for suspected subhepatic and subphrenic abscess, acute cholecystitis, small bowel obstruction, and intra-abdominal hemorrhage. The majority of the abscesses were polymicrobic infections with gram-negative enteric pathogens predominating. (Table I.) Klebsiella, Enterobacter, and Escherichia coli were encountered most frequently. Wound, sputum, and urine cultures often demonstrated the same organisms found in the pancreatic abscess. Complications of pancreatic abscess were frequent and multiple. (Figure 2.) Pulmonary difficulties, including pleural effusion, atelectasis, and pneumonitis, were the most common complications. Pleural effusion was present in six patients. Bacteremia was documented in five of the six patients in whom at least one blood culture was obtained. In only one instance was the organism in the blood the same as that in the abscess. In an-
TABLE
I
Bacteriologic Results in Thirteen
Bacteria
-_
Polymicrobial Monomicrobial Undetermined* Klebsiella Enterobacter E coli Proteus Enterococcus Serratia Staphylococcus Streptococcus Salmonella * No postmortem
Patients Number of Patients
6 4 3 5 3 3 2 2 1 1 1 1
cultures reported.
45
Jones, Polk, and Fulton
i
5 Patients
RENAL
4
8 Patients
FAILU
3LWO”NO WOUND
Comments
riiiiq
i
f-iiiiq
INFECTION
I----WOUND
DEHISCENCE
PERFORATION INTO STOMACH
DEHISCENCE
HEMORRHAGE FROM ABSCESS
,i
SUBPHRENIC EXTENSION
Figure 2. Muffiple sysfem organ faifure secondary sepsis was the pattern of death.
fo
other patient, Racteroides fragilis was found only in the blood. The organism responsible for the bacteremia in the remaining three patients had previously been cultured from the wound or sputum. Multiple system organ failure secondary to sepsis, characterized by progressive pulmonary insufficiency, renal failure, and upper gastrointestinal bleeding, was the pattern of death in the five patients who died as a result. of delayed drainage or untreated pancreatic abscess. Premortem bacteremia was proved in two of the three patients in this group in whom blood cultures were obtained. Diabetes mellitus, persistent fistula, pancreatic insufficiency, and recurrence of the abscess did not occur.
UPPER ABDOMINAL OPERATIONS
PANCREATIC TRAUMA
4
1
ACUTE
ALCOHOLISM
SILIARY TRACT DISEASE
1
1
PANCREATITIS----,
RESOLUTION
4 LESSER SAC COLLECTION ,,?,,
CHRhC
INTERNAL
DRAINAGE
EXTERNAL
DRAINAGE
Figure 3. Schemafk represenfafkn of the pofenfial progression of lesser sac collections and indicated surgical treatment. (See fexf).
46
A high index of suspicion is necessary for a diagnosis of pancreatic abscess. Abscesses must be considered in patients presenting with progressive occult sepsis and peritonitis with a history of recent pancreatitis, biliary tract disease, alcoholism, pancreatic trauma, or upper abdominal operations. Delay in diagnosis and treatment is associated with significant morbidity and mortality [I31. In these patients, the average delay in surgical drainage after hospital admission was six days in the eight survivors. However, diagnosis and external drainage were delayed twenty-one days in the one treated patient who died. The presentation of pancreatic abscess is subtle, but certain findings are of definite value. A palpable, tender epigastric mass, reported in as many as 85 per cent of cases 151, was found in only three patients in the present. series but was diagnostically significant. Hyperamylasemia, a variable finding in other series [2,3,5,6], occurred in almost half the cases in this series and directed attention toward the pancreas. Thorough roentgenographic evaluation in this series and in the experience of others has frequently been shown to be diagnostic if employed [1-S]. Felson [7] has described the spectrum of radiologic findings in pancreatic abscess and considers extraluminal gas bubbles or loculated air of the lesser sac to be pathognomonic of this disease. Portable abdominal views after instillation of air into the stomach can be helpful [5]. However, contrast studies are even more valuable adjuncts in documenting pancreatic abscess. The critically ill, fragile, rapidly deteriorating patient should be subjected to vigorous roentgenographic evaluation in order to expeditiously arrive at a life-saving diagnosis. In this disease process, delay in diagnosis has been fatal. Dencker, Liedberg; and Tibblin [8] successfully employed selective arteriography in delineating abscess of the pancreas. The use of ultrasound scanning has been favorably noted by Miller, Bradley, Holm, and their associates [ 1,9,10] and this modality should be especially useful in finding the smaller abscess. There is general agreement that external drainage through a transperitoneal approach is the treatment of choice [l-3,5,6,8]. Marsupialization of large abscesses, suggested by Hoolooki, rJaffee, and Gliedman 111 1, is usually not applicable and offers no advantages over conventional external drainage. Internal drainage contribut,ed to t,he
The American Journal of Surgery
Pancreatic Abscess
fatal outcome of one patient in this series, has been associated with disastrous results in the experience of others [12], and is to be condemned as a form of treatment. Employment of this method of drainage in pancreatic abscess is a result of confusion over the typical progression of lesser sac accumulations. (Figure 3.) The incidence of lesser sac accumulations associated with acute pancreatitis is unknown. Regardless of the predisposing etiologic factors, the course of these collections is predictable. A certain number will resolve spontaneously. The remainder will persist and enlarge. An understanding of the pathophysiologic aspects of this latter group is of utmost importance to the surgeon. Lesser sac collections can be characterized as acute or chronic, with further subdivision of the chronic group into sterile (pseudocyst) and infected (abscess) categories. Appropriate treatment depends on the duration [13] as well as the specific characteristics of the individual lesser sac accumulation encountered at laparotomy. Criteria necessary for the use of internal drainage include: (1) clear, amber fluid obtained by needle aspiration which is negative for organisms and polymorphonuclear leukocytes on gram stain; (2) evidence of chronic inflammation; (3) a well formed cyst wall. Acute inflammation, cloudy fluid, or purulent material with or without the presence of organisms or white blood cells on gram stain, and a poorly differentiated cyst wall necessitate external drainage. The findings at laparotomy and the indicated treatment frequently, but not uniformly, coincide with the clinical presentation of the patient. Significant complications occur in that group of patients in whom the diagnosis is delayed or overlooked. Smaller abscesses, remaining undiagnosed, present particular hazards [3]. The cause of death in pancreatic abscess is sepsis, manifested in our experience by multiple system organ failure. Shields and Polk [14] have recently found that occult sepsis is a prevalent etiologic factor of multiple system organ failure after major trauma and in patients with severe surgical illness. Although the extent and severity of injury were essentially equal in the five patients with trauma, the two patients in whom the abscess was drained promptly avoided progressive sepsis and organ failure. In the three who died, antecedent shock, massive fluid therapy, pneumonia, nephrotoxic drugs, and stress were invoked as the causes of pulmonary insufficiency, renal failure, and upper gastrointestinal bleeding. The underlying sepsis from untreated
Volume 129, January 1975
pancreatic abscess was not recognized. Documented pancreatic injury with subsequent organ failure should alert the clinician to the possibility of pancreatic abscess. In the two uninjured patients who died, sepsis also resulted in multiple system organ failure. The over-all mortality in the present group of patients was 38 per cent. The mortality in those patients subjected to early surgical drainage was 11 per cent. This compares favorably with results previously reported [Z-3,5,6,8]. Summary Successful management of pancreatic abscess necessitates early diagnosis and prompt external surgical drainage. The infection is predominantly gram-negative and polymicrobic. Roentgenographic contrast studies are of particular diagnostic value. Prompt recognition and external drainage are associated most frequently with recovery. Multiple system organ failure is the typical pattern of death and should alert one to the possibility of occult sepsis, secondary to pancreatic abscess. References 1. Miller TA. Lindenauer SM, Frey CF. Stanley JC: Pancreatic abscess. Arch Surg 108: 545, 1974. 2. Steedman RA, Doering R, Carter R: Surgical aspects of pancreatic abscess. Surg Gynecol Obstet 125: 757, 1967. 3. Altemeier WA, Alexander JW: Pancreatic abscess. Arch Surg 87: 80. 1963. 4. Warshaw AL: Pancreatic abscess. N Engl J Med 287: 1234, 1972. 5. Farringer JL Jr, Robbins LB II, Pickens DR Jr: Abscesses of the pancreas. Surgery 60: 964. 1966. 6. Evans RC: Pancreatic abscess. Am J Surg 117: 537, 1969. 7. Felson B: Gas abscess of pancreas. JAMA 163: 637, 1957. 8. Dencker H. Liedberg G, Tibblin S: Surgical aspects of pancreatic abscess. Acta Chir Stand 138: 609. 1972. 9. Bradley EL Ill. Clements JL Jr: Implications of diagnostic ultrasound in the surgical management of pancreatic pseudocyst. Am J Surg 127: 163, 1974. IO. Holm HH: Ultrasonic scanning in the diagnosis of space-occupying lesions of the upper abdomen. Br J Radio/ 44: 25, 1971. Il. Boolooki H, Jaffee B, Gliedman ML: Pancreatic abscesses and lesser omental sac collections. Surg Gynecol Obstet 126: 1301, 1968. 12. Polk HC Jr, Zeppa R, Warren WD: Surgical significance of differentiation between acute and chronic pancreatic collections. Ann Surg 169: 444, 1969. 13. Warren WD, Marsh WH, Miller WH Jr: Experimental production of pseudocysts of the pancreas with preliminary observations on internal drainage. Surg Gynecol Obstet 105: 385, 1957, 14. Shields C, Polk HC Jr: Early reexploration in trauma patients with multiple system organ failure and occult sepsis. Presented at a meeting of the Surgical Section of the Southern Medical Association, Atlanta, Georgia, November 18-20. 1974.
47
Calvin E. Jones, MD, Louisville, Kentucky Hiram C. Polk, Jr, MD, Louisville, Kentucky Robert L. Fulton, MD, Louisville, Kentucky
Pancreatic abscess is an infrequent but potentially lethal infection described as a complication of acute pancreatitis [I 1. With rare exceptions [2], it is uniformly fatal if untreated [3]. The diagnosis is often obscured and delayed by a perplexing clinical presentation. Treatment may be compromised by frequent and multiple complications. Reported mortality after surgical drainage approximates 34 per cent [4]. A review of the experience at the Louisville General Hospital was accomplished to further delineate the clinical course of pancreatic abscess and assess the results of surgical treatment. Clinical Review Thirteen patients with pancreatic abscess were encountered at the Louisville General Hospital during the twenty year period ending January 1974. This represents an approximate incidence of pancreatic abscess of 3 per cent among patients hospitalized for acute pancreatitis during the same interval. The classic presentation of successfully treated acute pancreatitis followed in several weeks by recrudescence of symptoms and onset of a septic course was present in only one patient, although acute pancreatitis was found in all thirteen patients at operation or autopsy. From the Department of Surgery. University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky. Reprint requests should be addressed to Dr Calvin E. Jones, Department of Surgery, University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky 40201. Presented at the Fifteenth Annual Meeting of the Society for Surgery of the Alimentary Tract, San Francisco, California, May 21 and 22, 1974.
44
This series was comprised of ten men and three women with an age range of twenty-four to sixty-four years, the average being forty-one years. Biliary tract disease was present in five patients, chronic alcoholism in three, blunt pancreatic trauma in two, and penetrating pancreatic trauma in three. The diagnosis of pancreatic abscess was made preoperatively or at laparotomy in nine patients and at autopsy in the remaining four. Nausea, vomiting, and epigastric abdominal pain radiating to the back were the principal symptoms with fever, abdominal distention, and tenderness being the most common physical findings. (Figure 1.) A tender mass was palpable in only three patients. Pulmonary abnormalities, including left lower lobe pneumonitis, atelectasis, and pleural effusion, were present in eight patients. In general, signs and symptoms tended to be vague and nonspecific. Serum amylase determinations were obtained in all patients. Hyperamylasemia was present in six patients, returning to normal after surgical drainage in five. The sixth patient, in whom the diagnosis was made at autopsy, had an elevated amylase level until death. White blood cell counts ranging from 15,000 to 30,000 per mm3 were a consistent finding in every case. Other laboratory parameters were not of value in the assessment of these patients. Roentgenograms were of significant preoperative diagnostic value in six patients, and retrospectively in two more. Routine abdominal x-ray examinations were obtained in eleven patients and gave abnormal results in three. In one patient, in addition to loculated retrogastric air, the distance between the stomach and transverse colon was increased and interspersed with myriads of small bubbles not dissimilar in appearance to
The American Journal of Surgery
Pancreatic
fecal matter. Extraluminal air in the left,upper quadrant was noted in ,one patient, and loculated, retrogastric air in the lesser sac with anterior displacement of the stomach was seen in another. Contrast studies were extremely helpful in six of the eight patients evaluated in this manner. Upper gastrointestinal series in four patients demonstrated flattening and anterior displacement of the stomach, retrogastric extraluminal air, or widening and effacement of the duo.??nal loop. Intravenous pyelography, showing blurred contour and lateral displacement of the left kidney with extrinsic compression on the collecting system, was diagnostically useful in one patient. Sinus tract injection documented pancreatic abscess in another patient. Barium enema and an intravenous pyelogram gave normal results in two additional patients subsequently found to have pancreatic abscess. With two exceptions, the eight uninjured patients presented initially with evidence of peritonitis and occult progressive sepsis. One presented with acute pancreatitis followed by peritonitis. Another had undergone pancreatic cystogastrostomy three weeks after an episode of acute pancreatitis. Multiple postoperative complications developed, and three weeks later pancreatic abscess was diagnosed and drained externally. In this patient, internal drainage was inappropriately applied to the treatment of an early lesser sac collection and certainly contributed to the patient’s subsequent clinical course and death. Of the remaining six patients presenting with peritonitis, one had undergone cholecystectomy and exploration of the common bile duct one month previously. Another abscess occurred one year after cystoduodenostomy for pseudocyst of the head of the pancreas. The remaining four patients had no recent antecedent history of pancreatitis. Pancreatic abscesses after pancreatic trauma were encountered in five patients. One patient with a small caliber gunshot wound to the stomach and contusion of the tail of the pancreas was discharged asymptomatic one week after laparotomy with normal laboratory parameters and roentgenographic findings. He was readmitted the following week with signs of peritonitis, fixed left hemidiaphragm, and left pleural effusion. Pancreatic abscess was diagnosed at laparotomy. Another patient’s condition had improved significantly after a gunshot wound to the head of the pancreas until the tenth postoperative day when signs of sepsis and hemorrhage from the drain site occurred. Sinus tract injection demonstrated a pancreatic abscess. The remaining three patients with blunt (two) and penetrating (one) pancreatic trauma became septic during the first week after emergency laparotomy and had progressive multiple system organ failure and death with untreated pancreatic abscess. Nine patients were treated and eight survived. External drainage was employed in eight and internal gastric drainage in one. The interval between hospital admission and successful diagnosis and drainage averaged six days in the survivors. One patient in whom the diagnosis
Votume129.Januan1975
Abscess
Figure 1. Symptoms and physlcal findings are vague and nonspecific. was delayed three weeks died after external drainage. Four patients were not treated, and none survived. Preoperative assessment was correct in four patients. The remaining five underwent exploratory laparotomy for suspected subhepatic and subphrenic abscess, acute cholecystitis, small bowel obstruction, and intra-abdominal hemorrhage. The majority of the abscesses were polymicrobic infections with gram-negative enteric pathogens predominating. (Table I.) Klebsiella, Enterobacter, and Escherichia coli were encountered most frequently. Wound, sputum, and urine cultures often demonstrated the same organisms found in the pancreatic abscess. Complications of pancreatic abscess were frequent and multiple. (Figure 2.) Pulmonary difficulties, including pleural effusion, atelectasis, and pneumonitis, were the most common complications. Pleural effusion was present in six patients. Bacteremia was documented in five of the six patients in whom at least one blood culture was obtained. In only one instance was the organism in the blood the same as that in the abscess. In an-
TABLE
I
Bacteriologic Results in Thirteen
Bacteria
-_
Polymicrobial Monomicrobial Undetermined* Klebsiella Enterobacter E coli Proteus Enterococcus Serratia Staphylococcus Streptococcus Salmonella * No postmortem
Patients Number of Patients
6 4 3 5 3 3 2 2 1 1 1 1
cultures reported.
45
Jones, Polk, and Fulton
i
5 Patients
RENAL
4
8 Patients
FAILU
3LWO”NO WOUND
Comments
riiiiq
i
f-iiiiq
INFECTION
I----WOUND
DEHISCENCE
PERFORATION INTO STOMACH
DEHISCENCE
HEMORRHAGE FROM ABSCESS
,i
SUBPHRENIC EXTENSION
Figure 2. Muffiple sysfem organ faifure secondary sepsis was the pattern of death.
fo
other patient, Racteroides fragilis was found only in the blood. The organism responsible for the bacteremia in the remaining three patients had previously been cultured from the wound or sputum. Multiple system organ failure secondary to sepsis, characterized by progressive pulmonary insufficiency, renal failure, and upper gastrointestinal bleeding, was the pattern of death in the five patients who died as a result. of delayed drainage or untreated pancreatic abscess. Premortem bacteremia was proved in two of the three patients in this group in whom blood cultures were obtained. Diabetes mellitus, persistent fistula, pancreatic insufficiency, and recurrence of the abscess did not occur.
UPPER ABDOMINAL OPERATIONS
PANCREATIC TRAUMA
4
1
ACUTE
ALCOHOLISM
SILIARY TRACT DISEASE
1
1
PANCREATITIS----,
RESOLUTION
4 LESSER SAC COLLECTION ,,?,,
CHRhC
INTERNAL
DRAINAGE
EXTERNAL
DRAINAGE
Figure 3. Schemafk represenfafkn of the pofenfial progression of lesser sac collections and indicated surgical treatment. (See fexf).
46
A high index of suspicion is necessary for a diagnosis of pancreatic abscess. Abscesses must be considered in patients presenting with progressive occult sepsis and peritonitis with a history of recent pancreatitis, biliary tract disease, alcoholism, pancreatic trauma, or upper abdominal operations. Delay in diagnosis and treatment is associated with significant morbidity and mortality [I31. In these patients, the average delay in surgical drainage after hospital admission was six days in the eight survivors. However, diagnosis and external drainage were delayed twenty-one days in the one treated patient who died. The presentation of pancreatic abscess is subtle, but certain findings are of definite value. A palpable, tender epigastric mass, reported in as many as 85 per cent of cases 151, was found in only three patients in the present. series but was diagnostically significant. Hyperamylasemia, a variable finding in other series [2,3,5,6], occurred in almost half the cases in this series and directed attention toward the pancreas. Thorough roentgenographic evaluation in this series and in the experience of others has frequently been shown to be diagnostic if employed [1-S]. Felson [7] has described the spectrum of radiologic findings in pancreatic abscess and considers extraluminal gas bubbles or loculated air of the lesser sac to be pathognomonic of this disease. Portable abdominal views after instillation of air into the stomach can be helpful [5]. However, contrast studies are even more valuable adjuncts in documenting pancreatic abscess. The critically ill, fragile, rapidly deteriorating patient should be subjected to vigorous roentgenographic evaluation in order to expeditiously arrive at a life-saving diagnosis. In this disease process, delay in diagnosis has been fatal. Dencker, Liedberg; and Tibblin [8] successfully employed selective arteriography in delineating abscess of the pancreas. The use of ultrasound scanning has been favorably noted by Miller, Bradley, Holm, and their associates [ 1,9,10] and this modality should be especially useful in finding the smaller abscess. There is general agreement that external drainage through a transperitoneal approach is the treatment of choice [l-3,5,6,8]. Marsupialization of large abscesses, suggested by Hoolooki, rJaffee, and Gliedman 111 1, is usually not applicable and offers no advantages over conventional external drainage. Internal drainage contribut,ed to t,he
The American Journal of Surgery
Pancreatic Abscess
fatal outcome of one patient in this series, has been associated with disastrous results in the experience of others [12], and is to be condemned as a form of treatment. Employment of this method of drainage in pancreatic abscess is a result of confusion over the typical progression of lesser sac accumulations. (Figure 3.) The incidence of lesser sac accumulations associated with acute pancreatitis is unknown. Regardless of the predisposing etiologic factors, the course of these collections is predictable. A certain number will resolve spontaneously. The remainder will persist and enlarge. An understanding of the pathophysiologic aspects of this latter group is of utmost importance to the surgeon. Lesser sac collections can be characterized as acute or chronic, with further subdivision of the chronic group into sterile (pseudocyst) and infected (abscess) categories. Appropriate treatment depends on the duration [13] as well as the specific characteristics of the individual lesser sac accumulation encountered at laparotomy. Criteria necessary for the use of internal drainage include: (1) clear, amber fluid obtained by needle aspiration which is negative for organisms and polymorphonuclear leukocytes on gram stain; (2) evidence of chronic inflammation; (3) a well formed cyst wall. Acute inflammation, cloudy fluid, or purulent material with or without the presence of organisms or white blood cells on gram stain, and a poorly differentiated cyst wall necessitate external drainage. The findings at laparotomy and the indicated treatment frequently, but not uniformly, coincide with the clinical presentation of the patient. Significant complications occur in that group of patients in whom the diagnosis is delayed or overlooked. Smaller abscesses, remaining undiagnosed, present particular hazards [3]. The cause of death in pancreatic abscess is sepsis, manifested in our experience by multiple system organ failure. Shields and Polk [14] have recently found that occult sepsis is a prevalent etiologic factor of multiple system organ failure after major trauma and in patients with severe surgical illness. Although the extent and severity of injury were essentially equal in the five patients with trauma, the two patients in whom the abscess was drained promptly avoided progressive sepsis and organ failure. In the three who died, antecedent shock, massive fluid therapy, pneumonia, nephrotoxic drugs, and stress were invoked as the causes of pulmonary insufficiency, renal failure, and upper gastrointestinal bleeding. The underlying sepsis from untreated
Volume 129, January 1975
pancreatic abscess was not recognized. Documented pancreatic injury with subsequent organ failure should alert the clinician to the possibility of pancreatic abscess. In the two uninjured patients who died, sepsis also resulted in multiple system organ failure. The over-all mortality in the present group of patients was 38 per cent. The mortality in those patients subjected to early surgical drainage was 11 per cent. This compares favorably with results previously reported [Z-3,5,6,8]. Summary Successful management of pancreatic abscess necessitates early diagnosis and prompt external surgical drainage. The infection is predominantly gram-negative and polymicrobic. Roentgenographic contrast studies are of particular diagnostic value. Prompt recognition and external drainage are associated most frequently with recovery. Multiple system organ failure is the typical pattern of death and should alert one to the possibility of occult sepsis, secondary to pancreatic abscess. References 1. Miller TA. Lindenauer SM, Frey CF. Stanley JC: Pancreatic abscess. Arch Surg 108: 545, 1974. 2. Steedman RA, Doering R, Carter R: Surgical aspects of pancreatic abscess. Surg Gynecol Obstet 125: 757, 1967. 3. Altemeier WA, Alexander JW: Pancreatic abscess. Arch Surg 87: 80. 1963. 4. Warshaw AL: Pancreatic abscess. N Engl J Med 287: 1234, 1972. 5. Farringer JL Jr, Robbins LB II, Pickens DR Jr: Abscesses of the pancreas. Surgery 60: 964. 1966. 6. Evans RC: Pancreatic abscess. Am J Surg 117: 537, 1969. 7. Felson B: Gas abscess of pancreas. JAMA 163: 637, 1957. 8. Dencker H. Liedberg G, Tibblin S: Surgical aspects of pancreatic abscess. Acta Chir Stand 138: 609. 1972. 9. Bradley EL Ill. Clements JL Jr: Implications of diagnostic ultrasound in the surgical management of pancreatic pseudocyst. Am J Surg 127: 163, 1974. IO. Holm HH: Ultrasonic scanning in the diagnosis of space-occupying lesions of the upper abdomen. Br J Radio/ 44: 25, 1971. Il. Boolooki H, Jaffee B, Gliedman ML: Pancreatic abscesses and lesser omental sac collections. Surg Gynecol Obstet 126: 1301, 1968. 12. Polk HC Jr, Zeppa R, Warren WD: Surgical significance of differentiation between acute and chronic pancreatic collections. Ann Surg 169: 444, 1969. 13. Warren WD, Marsh WH, Miller WH Jr: Experimental production of pseudocysts of the pancreas with preliminary observations on internal drainage. Surg Gynecol Obstet 105: 385, 1957, 14. Shields C, Polk HC Jr: Early reexploration in trauma patients with multiple system organ failure and occult sepsis. Presented at a meeting of the Surgical Section of the Southern Medical Association, Atlanta, Georgia, November 18-20. 1974.
47