A 48-year-old man is evaluated in the emergency department for left flank pain and dysuria. Six months earlier, the patient was hospitalized for severe acute gallstone pancreatitis. Contrast-enhanced CT of the pancreas showed lack of perfusion in the body of the pancreas. He recovered with supportive care and was discharged 2 weeks later. He had an uncomplicated laparoscopic cholecystectomy 4 weeks after discharge. He reports that he has felt well until the sudden onset of left flank pain today.
On physical examination, blood pressure is 130/80 mm Hg and pulse rate is 90/min; other vital signs are normal. Abdominal examination is notable for pain in the left lower quadrant on palpation. The remainder of the examination is normal.
Urinalysis shows hematuria.
A CT scan identifies nephrolithiasis and a small stone in the left ureter. The CT scan also shows a 6-cm fluid collection with solid debris in the body of the pancreas with a well-defined wall.
Which of the following is the most appropriate management of the fluid collection?
A. Antibiotic therapy
B. CT-guided fine-needle aspiration
C. Drainage procedure
MKSAP Answer and Critique
The correct answer is D. Observation. This content is available to MKSAP 18 subscribers as Question 95 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The most appropriate management of the fluid collection is observation. Walled-off necrosis of the pancreas is the most likely diagnosis. The pancreatic fluid collection incidentally found during kidney stone–protocol CT corresponds to the location of pancreatic necrosis during his acute gallstone pancreatitis 6 months earlier. By definition, acute necrotic collections are classified as walled-off necrosis after 4 weeks. The necrotic tissue liquifies with time and develops a mature wall as part of the healing process, as seen on imaging. These fluid collections do not require therapy if they are asymptomatic, and as many as 60% may resolve spontaneously within 1 year; fluid-related complications are rare.
Areas of pancreatic necrosis are frequently identified on imaging during an episode of acute pancreatitis. Patients with uninfected pancreatic necrosis do not benefit from antibiotic use during the acute phase of pancreatitis or later, in the resolving stage. Patients whose condition does not improve or deteriorates 7 to 10 days after presentation of acute pancreatitis may have infected necrosis. CT-guided fine-needle aspiration may help guide treatment decisions regarding antibiotic use, drainage, and continued supportive care. Neither CT-guided fine-needle aspiration nor antibiotic therapy is needed in this asymptomatic patient with walled-off necrosis of the pancreas that is likely to resolve spontaneously. The patient's left flank pain is due to passage of a kidney stone, not the pancreatic fluid collection.
Many walled-off necroses of the pancreas resolve spontaneously, but some persist, enlarge, have a mass effect, and/or cause symptoms. Symptomatic collections may require decompression or debridement. However, this patient is asymptomatic and no intervention is required at this time.
- Asymptomatic patients with walled-off necrosis of the pancreas require no intervention.