Emphysematous pancreatitis. Radiological curiosity or a cause for concern?

CONTEXT Emphysematous pancreatitis is a rare, potentially fatal variant of severe acute pancreatitis with gas in the pancreatic bed. There are isolated case reports describing this condition. OBJECTIVE This report summarizes our experience with the management of this condition in order to compare its clinical characteristics, microbiological and radiological features, surgical management and the outcome of patients with emphysematous pancreatitis and non-emphysematous infected pancreatic necrosis. SETTING The hospital records of the patients who underwent necrosectomy for infected pancreatic necrosis between 2002 and 2006 were reviewed. PATIENTS Fifty-seven patients were identified: 11 of them (19.3%) had gas in and around the pancreas on computed tomography and 46 (80.7%) had non-emphysematous infected pancreatic necrosis. MAIN OUTCOME MEASURES The clinical characteristics and the hospital course of the two groups of patients were compared. RESULTS The mean age of 11 patients with emphysematous pancreatitis was 34.0+/-11.5 years and alcohol was the most common etiology (54.5%). The median computed tomography severity index was 10. All 11 patients with emphysematous pancreatitis had growth of organisms on culture of fine needle aspiration or pancreatic tissue obtained at surgery, with Escherichia coli in all of them. Polymicrobial infection was seen in 5 (45.5%) of them. In comparing patients having emphysematous pancreatitis with those having non-emphysematous infected necrosis, there was no significant difference in the severity of the disease (P=0.319), time to surgical intervention (P=0.553), incidence of organ failure (P=0.297), hospital stay (P=0.580) or mortality rate (P=0.739). The total number of locoregional complications was significantly higher in patients with emphysematous pancreatitis (P=0.049). However, when compared separately, the incidence of enteric fistula, bleeding, intra-abdominal collections and wound complications were similar in the two groups (P>0.250). CONCLUSION Emphysematous pancreatitis is easily diagnosed on computed tomography and all patients require surgical intervention. The clinical course and prognosis is not different from that of infected pancreatic necrosis.