Successful Multidisciplinary Management of Severe Acute Necrotizing Pancreatitis in a 27 Y.O. Male
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully managed a 27-year-old male patient diagnosed with severe acute necrotizing pancreatitis with walled-off pancreatic necrosis (WOPN), complicated by pleural effusion and left internal jugular vein thrombosis. Management involved multiple advanced interventions, including percutaneous drainage, endoscopic necrosectomy with cystogastrostomy, mechanical thrombectomy, and balloon venoplasty. The multidisciplinary treatment focused on controlling pancreatic necrosis, managing associated complications, supporting nutrition, and stabilizing the patient for recovery.
Chief complaints
A 27-year-old male patient with a body mass index (BMI) of 20 presented to the Gastroenterology Department at PACE Hospitals, Hyderabad with a known history of severe acute necrotizing pancreatitis and walled-off pancreatic necrosis (WOPN). He had previously undergone multiple interventions, including percutaneous drainage (PCD), necrosectomy, and thrombectomy, for complications related to the condition.
The patient came to the hospital approximately one month later with complaints of abdominal bloating and intermittent fever for two days. His clinical history and symptoms raised concern for persistent pancreatic inflammation and complications related to the necrotic collection. He was admitted for further evaluation and advanced management.
Past Medical history
The patient had a history of alcohol-induced severe
acute necrotizing pancreatitis, complicated by walled-off pancreatic necrosis (WOPN), left loculated pleural effusion, and left internal jugular vein (IJV) thrombosis. He had previously undergone percutaneous catheter drainage (PCD), necrosectomy, and thrombectomy for management of these complications. No known drug or food allergies were reported.
On Examination
On examination, the patient was conscious, coherent, and alert. His general condition was stable, with no signs of acute distress. There was no pallor on examination. A percutaneous drainage (PCD) catheter was noted to be in situ in the epigastric region.
His pulse rate, blood pressure, respiratory rate, and oxygen saturation were within normal limits. Abdominal examination was performed to assess the extent of abdominal distension and ongoing pancreatic disease.
Diagnosis
Following admission, the patient underwent a detailed clinical evaluation, including assessment of his previous history of severe acute pancreatitis, complications, prior interventions, and current symptoms.
Laboratory investigations showed elevated liver enzymes, with increased AST and ALT levels. Alkaline phosphatase (ALP) was also elevated, while serum albumin was low. C-reactive protein (CRP) was markedly elevated, indicating significant ongoing inflammation. These findings were assessed along with the patient's clinical condition and imaging findings.
The patient was diagnosed with severe acute necrotizing pancreatitis with walled-off pancreatic necrosis (WOPN) involving the pancreatic head. The condition was associated with a left loculated pleural effusion and left internal jugular vein (IJV) thrombosis.
Based on the clinical assessment, the patient was advised to undergo
severe Acute Necrotizing Pancreatitis Treatment in Hyderabad, India, and its complications under the expert care of the Gastroenterology team with multidisciplinary monitoring.
Medical Decision-Making (MDM)
After detailed evaluation by Dr. Govind Verma, Interventional Gastroenterologist, Transplant Hepatologist, Pancreatologist, and Endosonologist, along with cross-consultants Dr. M Sudhir and Dr. Padma Priya, the patient's condition was assessed as severe acute necrotizing pancreatitis complicated by walled-off pancreatic necrosis, pleural effusion, and left IJV thrombosis.
Considering the extent of pancreatic necrosis and the associated complications, a multidisciplinary treatment approach was planned. The management focused on adequate drainage of the necrotic collection, removal of devitalized pancreatic tissue, treatment of the venous thrombosis, management of the pleural effusion, and maintenance of adequate nutritional support.
A percutaneous drainage catheter was used to facilitate drainage of the pancreatic collection. Endoscopic intervention was planned to establish internal drainage and remove necrotic tissue. In view of the left IJV thrombosis, mechanical removal of the thrombus followed by balloon venoplasty was undertaken to restore venous blood flow.
The patient and his family were counselled regarding the severity of the pancreatic disease, the complications involved, the need for multiple interventions, nutritional support, alcohol abstinence, and the importance of close follow-up after discharge.
Treatment
Following the multidisciplinary treatment plan, the patient underwent advanced management for severe acute necrotizing pancreatitis in Hyderabad at PACE Hospitals along with walled-off pancreatic necrosis, left pleural effusion, and left internal jugular vein thrombosis.
A percutaneous catheter drainage (PCD) catheter was placed in the epigastric region to drain the pancreatic collection and facilitate the removal of fluid and debris.
The patient subsequently underwent transgastric necrosectomy with cystogastrostomy. During this procedure, necrotic pancreatic tissue was removed and an internal connection was created between the pancreatic collection and the stomach to facilitate drainage.
For the left internal jugular vein thrombosis, mechanical thrombectomy was performed to remove the thrombus. This was followed by balloon venoplasty to improve venous flow and restore vessel patency.
Nutritional support was an important part of the patient's recovery. He had been receiving nasojejunal (NJ) feeding for approximately three weeks because of severe abdominal discomfort and pancreatitis. His nutritional status was monitored during treatment, particularly in view of the low albumin levels and prolonged illness.
The patient was managed with close clinical monitoring and multidisciplinary care for the pancreatic, vascular, pleural, and nutritional complications.
Discharge Medications
At discharge, the patient was prescribed medications for pain relief, control of nausea and vomiting, gastric protection, management of pancreatic and digestive symptoms, and prevention or treatment of infection when indicated. Appropriate medication was also advised for management of the left internal jugular vein thrombosis following the thrombectomy and balloon venoplasty.
Advice on Discharge
The patient was advised to follow a
low-fat, high-protein diet, maintain adequate hydration, and completely avoid alcohol to support pancreatic recovery and reduce the risk of recurrence. He was also advised to take prescribed medications regularly and attend scheduled follow-up appointments for monitoring of pancreatic and associated complications.
Emergency Care
The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as high-grade fever, severe or worsening abdominal pain, increasing abdominal distension, persistent vomiting, breathing difficulty, or any other alarming symptoms.
Review and Follow-Up Notes
The patient was advised to return for a follow-up with the Gastroenterologist in Hyderabad at PACE Hospitals after 1 week.
Conclusion
This case highlights the complexity of severe acute necrotizing pancreatitis complicated by walled-off pancreatic necrosis, pleural effusion, and left internal jugular vein thrombosis. Timely multidisciplinary management with drainage, necrosectomy, thrombectomy, and nutritional support helped stabilize the patient and support recovery.
Multidisciplinary Approach to Severe Acute Necrotizing
Pancreatitis
Severe acute necrotizing pancreatitis can affect multiple organ systems and may require coordinated care from gastroenterologists, pancreatologists, interventional endoscopists, radiologists, A Gastroenterologist / Gastroenterology doctor, critical care specialists, and nutrition teams. Management may involve drainage of infected or symptomatic pancreatic collections, endoscopic or surgical removal of necrotic tissue, treatment of vascular complications, and nutritional support.
When walled-off pancreatic necrosis develops, treatment is generally individualized according to the patient's symptoms, infection status, collection characteristics, and associated complications. Close monitoring and timely intervention are important when complications such as pleural effusion or venous thrombosis occur. Long-term follow-up and complete avoidance of alcohol are particularly important in patients with alcohol-associated pancreatitis to reduce the risk of recurrent pancreatic injury.
Frequently asked questions(FAQs)
What is walled-off pancreatic necrosis (WOPN)?
WOPN develops when dead pancreatic tissue and fluid collect and become enclosed by a wall after severe pancreatitis. It usually takes several weeks to form. If the collection causes ongoing problems or becomes infected, drainage or removal of the dead tissue may be needed.
Why was a PCD catheter placed for this patient?
The PCD catheter was used to drain the pancreatic collection through the skin. This helps remove fluid and infected or dead material from the collection. In selected patients, drainage may control the problem without the need for immediate major surgery.
What does transgastric necrosectomy with cystogastrostomy mean?
Cystogastrostomy creates a passage between the pancreatic collection and the stomach so that the contents can drain into the stomach. Necrosectomy is done to remove dead pancreatic tissue that remains inside the collection. These procedures can be used when drainage alone is not enough.
Is surgery always needed for pancreatic necrosis?
No. Not every patient with pancreatic necrosis needs an operation. The decision depends on the patient's condition, symptoms, infection, and how the collection is behaving. When treatment is required, doctors may first consider endoscopic or catheter drainage and use surgery when other approaches are not suitable or successful.
Why were several procedures needed in this case?
The patient had more than one complication from severe pancreatitis. The pancreatic collection required drainage and necrosectomy, while the clot in the internal jugular vein needed thrombectomy and venoplasty. The pleural effusion also required continued assessment.
Why was thrombectomy performed for the internal jugular vein clot?
A clot in the internal jugular vein can interfere with normal blood flow and may lead to further complications. Mechanical thrombectomy was performed to remove the clot from the affected vein. Balloon venoplasty was then used to improve the passage of blood through the narrowed or affected section.
Why was NJ feeding continued for several weeks?
The patient had severe pancreatitis and significant abdominal discomfort, making normal eating difficult. NJ feeding allowed him to receive nutrition directly into the small intestine. Maintaining adequate nutrition is an important part of recovery from severe necrotizing pancreatitis.
Why did this patient develop pleural effusion?
Severe pancreatitis can sometimes cause fluid to collect around the lungs. This is called a pleural effusion. Some cases improve as the pancreatic inflammation settles, while a persistent or complicated effusion may need further treatment.
What should patients eat after recovering from severe pancreatitis?
Food should be introduced according to the treating doctor's advice and should provide enough calories and protein for recovery. A low-fat diet may be recommended depending on the patient's condition and tolerance. In alcohol-related pancreatitis, avoiding alcohol completely is especially important.
Why are regular follow-ups needed after treatment for WOPN?
The pancreatic collection may take time to settle even after drainage and necrosectomy. Follow-up helps check the progress of healing and look for problems such as a persistent collection, pleural effusion, or vascular complications. Further treatment can be planned if any of these problems continue.
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