Early endoscopic management of an infected acute necrotic collection misdiagnosed as a pancreatic pseudocyst: A case report

Abstract

Background: Infected acute necrotic collection (ANC) is a fatal complication of acute pancreatitis with substantial morbidity and mortality. Drainage plays an exceedingly important role as the first step in invasive intervention for infected necrosis; however, there is great controversy about the optimal drainage time, and better treatment should be explored.

Case summary: We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancreatitis; conservative treatment was ineffective, and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography (CT). Endoscopic ultrasonography (EUS) suggested hyperechoic necrotic tissue within the cyst cavity. The wall was not completely mature, and the culture of the puncture fluid was positive for A-haemolytic Streptococcus. Thus, the final diagnosis of ANC infection was made. The necrotic collection was not walled off and contained many solid components; therefore, the patient underwent EUS-guided aspiration and lavage. Two weeks after the collection was completely encapsulated, pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography (ERCP) was performed, and the patient was subsequently successfully discharged. On repeat CT, the pancreatic cysts had almost disappeared during the 6-month follow-up period after surgery.

Conclusion: Early EUS-guided aspiration and lavage combined with late ERCP catheter drainage may be effective methods for intervention in infected ANCs.

Keywords: Case report; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasonography; Endoscopic ultrasound-guided fine-needle aspiration; Infected acute necrotic collection; Pancreatic pseudocyst.

Figure 1

Contrast-enhanced computed tomography. A: On February 13, 2023, multiple cysts were seen in the hepato-gastric space, low-attenuated, homogeneous fluid collections, with a maximum diameter of 89 mm × 76 mm, the cyst was communicates with the pancreatic duct (orange triangle); B: The cyst size was about 40 mm × 59 mm after 3 d of the first intervention; C: Two weeks later, computed tomography examination before the second intervention showed that the cyst size was similar to the last check; D: After 3 months of follow-up, the size of the cyst was about 27 mm × 22 mm; E: After 6 months of follow-up, the size of the cyst was about 6 mm × 8 mm.

Figure 2

Endoscopic ultrasound-guided aspiration and lavage. A: The size of the cyst cavity was 56 mm × 36 mm, with necrotic debris (orange triangle), and the necrotic collection was not walled-off (orange arrows); B: The cystic cavity almost disappeared after intervention.

Figure 3

Endoscopic retrograde cholangiopancreatography pancreatic duct stent drainage. A: The guidewire was inserted into the pancreatic duct through an incision knife; B: Iodophor angiography; C: A 5-7 Fr plastic pancreatic stent was placed in the main pancreatic duct under fluoroscopy; D: X-ray fluoroscopy stent was in a good position.