A CASE OF EXTRA PANCREATIC NECROTISING PANCREATITIS

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Fever of unknown origin how we ALMOST MISSED IT ! :

Fever of unknown origin how we ALMOST MISSED IT ! ACKNOWLEDGEMENTS KIMS GENERAL SURGERY DEPT : DR KN VIJAYAN DR SHAFI DR ARUN KUMAR PATHOLOGY DEPT DR LEENA RADIOLOGY DEPT

prelude :

A 24 yr old primi with term pregnancy was referred from local hospital with - Fever with chills since 1 weeks - Cough since 5-6 days Pt was admitted for safe confinement Induction of labor failed and hence emerg LSCS was done Post-op she had abdominal distention and ↓urine output P/A: distended, diffuse tenderness, no free fluid, ↓BS X ray: Distended bowel loops TLC- 13300 ; ; Hb : 15.6 ; CRP : 321 ; K+=3.1 ∆: Post op paralytic Ileus Managed conservatively, hypokalemia corrected and discharged BUT PATIENT STILL HAD INTERMITTENT FEVER SPIKES! prelude

First visit (26/7):

6 days later pt presented with - Persistent fever with chills - Abdominal pain and distention P/A: Free fluid + TLC-20,500 , Hb-8.7 CRP-228 Lipase – 216 (N < 140) ; Amylase – 85 (N < 130) First visit (26/7)

investigations:

CXR : WNL USG Abdomen : Moderate ascitis ;(L) Pleural effusion Rapid malaria test : Leptospira IgM : Blood culture : Urine culture : Pt was started on iv antibiotics CT abdo was advised investigations NEGATIVE

Ct abdomen:

Ct abdomen

PowerPoint Presentation:

L K K

PowerPoint Presentation:

Fat stranding

PowerPoint Presentation:

Moderate ascitis K K L

PowerPoint Presentation:

Fat stranding

PowerPoint Presentation:

Inflamed mesentery

PowerPoint Presentation:

P

Ascitic fluid analysis:

Fluid amylase lipase Gram stain : AFB staining : Differential count: ADA ( >30 = TB) AFB culture C/S: NORMAL FEW PUS CELLS NEGATIVE P-57% ; L-43% NORMAL (report not ready) (report not ready) Ascitic fluid analysis USG guided tapping of the ascitic fluid was done

Continues…:

Meanwhile fever spikes continued Antibiotics were stepped up Medical board was kept And it was decided to go for diagnostic lap Continues…

Diagnostic laparoscopy- Dr shafi :

Diagnostic laparoscopy- Dr shafi Moderate ascitis straw colored Cob webbing Extensive deposits seen all over Omental biopsy was taken

Discharge (3/8):

Gradually fever spikes came down and then counts became normal Pt was started on ATT emperically She was discharged with antibiotics Ascitic Fluid C/S : NO GROWTH CRP- ↓97 Discharge diagnosis : peritonitis possibly TB BUT PATIENT STILL HAD INTERMITTENT FEVER SPIKES! Discharge (3/8)

third visit (6/8):

3 days after discharge pt again presented with - persistent fever, vomiting and tiredness O/E: pallor + ; Icterus + ; tachypnoea + P/A: soft , Generalised Tendernesss + ; More on Lt side Free fluid + ; BS – sluggish ; Ascitic fluid C/S: Late growth of ESBL E.Coli third visit (6/8)

investigations:

TLC : 24 ,000 Hb : 9.5 CRP: 242 LFT: ALP 368 ; AST 53 ; ALT 132 Lipase – 118 (N < 140) ; Amylase - 58 (N < 130 ) Omental biopsy : No granuloma, Foamy macrophages+ ; FAT NECROSIS CXR – s/o ARDS investigations

PowerPoint Presentation:

ATT was stopped promptly Portable USG : No ascitis , (R) Pleural effusion Working ∆ : Extensive periotoneal TB with secondary bacterial infection leading to severe sepsis & ARDS Broad Spectrum Antibiotics and anti fungals were continued CECT abdo advised

CECT Abdomen:

CECT Abdomen

CT guided percutaneous drainage:

CT guided percutaneous drainage was done which was purulent. In view of air in the retro peritoneum and pus in percutaneous drainage it was decided to explore the retro peritoneum CT guided percutaneous drainage

Laparotomy- DR arunkumar & dr kn vijayan:

Laparotomy- DR arunkumar & dr kn vijayan Omentum and mesentry showed saponification Rest of the viscera was normal Medial visceral rotation of both sides were done Extensive fat necrosis with pus was seen in the retro peritoneum Body and tail of pancreas appeared normal 80-90% of the necrotic infected retro peritoneal fat removed

postop:

Pt developed respiratory distress and was intubated and then extubated on 5 th POD Fever improved But there was persistent tachycardia. ECHO- showed dilated cardiomyopathy with EF- 25 % Pt was heparinised and put on warfarin and digoxin under cardiology consultation . She also developed Lt fasciobrachial monoparesis as a result of an embolic stroke She also had antibiotic associated colitis Serial ECHO showed EF-40 % Pt was then discharged after 31 days of admission ! postop

summary:

Lipase amylase : slightly raised Diagnostic lap : deposits all over Ascitic fluid analysis : ADA normal , amylase lipase normal Omental biopsy : fat necrosis CECT : Retro peritoneal fat necrosis Laparotomy : normal pancreas with retro peritoneal pus and necrotic material DIAGNOSIS : ??? summary Persistent fever , ascites ; CRP and TC raised

literature:

According to the Atlanta classification, necrotising pancreatitis was defined as diffuse or focal area(s) of non-viable pancreatic parenchyma typically associated with extrapancreatic fat necrosis This definition did not include patients with extrapancreatic necrosis only ( EXPN). literature

Existing study:

Existing study

The pathophysiological explanation :

It is generally believed that trypsin activation leads to autodigestion and local inflammation . Its suggested that the compartment of peripheral acinar cells may represent the source of enzymes for the autodigestive necrosis of fat in peripancreatic tissues . I n EXPN, necrosis of the acinar cells does not seem to occur and the pancreatic parenchyma is preserved ; potential explanation may be that the amount of released inflammatory mediators or cytokines in EXPN is lower. The pathophysiological explanation

Expn VS Tb:

Expn VS Tb

Thank you:

Thank you

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