Acute Necrotizing Pancreatitis With Infected Peripancreatic Collections and Upper Gastrointestinal Bleed Managed Via Multimodal Endoscopic Intervention

Abstract

Acute pancreatitis is a common but potentially life-threatening condition. Although most cases are self-limiting, severe forms such as necrotizing pancreatitis can lead to local complications like pancreatic necrosis or acute necrotic collections (with or without infection), as well as systemic complications such as gastrointestinal bleeding. Management becomes more complex when these complications coexist. A 37-year-old man with no prior comorbidities presented with epigastric pain and vomiting. After imaging, he was found to have choledocholithiasis with acute biliary pancreatitis. After endoscopic retrograde pancreatography and biliary duct stenting, the patient continued to have a fever along with the development of pain, and computerized tomography showed features of necrotizing pancreatitis with evolving fluid collections. Despite conservative treatment, he developed infected necrotic collections requiring endoscopic cystogastrostomy and placement of a lumen-apposing metal stent. A complication of upper GI bleeding occurred during the procedure. Cultures from the drained collection revealed Klebsiella pneumoniae, Enterobacter, and Enterococcus faecium. After three sessions of endoscopic necrosectomy, significant clinical improvement was observed. This case demonstrates a rare yet crucial clinical situation of concomitant infected necrosis and gastrointestinal hemorrhage during the procedure of endoscopic drainage, which necessitated a stepped-up multimodal approach. It underscores the importance of early multidisciplinary decision-making and endoscopic innovation in managing complex pancreatitis.

Keywords: acute necrotizing pancreatitis; acute pancreatitis; cbd stenting; endoscopic necrosectomy; ercp; eus-guided drainage; lumen-apposing metal stent (lams); peripancreatic collection; severe acute pancreatitis (sap); upper gi bleed.

Figure 1. Ultrasound of the abdomen showing the distended gall bladder and common bile duct with multiple calculi (Oct 21, 2024)

Abdominal ultrasound demonstrating a distended gallbladder containing multiple calculi (aggregate size up to 15 mm) with mild wall thickening as shown by the blue arrow. The common bile duct (CBD) is dilated to 12 mm, showing an echogenic focus consistent with an obstructing 6 mm CBD stone (red arrow). No pericholecystic fluid or intrahepatic biliary dilation is observed. These findings support the diagnosis of acute biliary pancreatitis secondary to choledocholithiasis.

Figure 2. ERCP fluoroscopy showing distal CBD stone with sphincterotomy and biliary stent (Oct 23, 2024)

ERCP: Endoscopic Retrograde Cholangiopancreatography, CBD: Common Bile Duct

Figure 3. Contrast-enhanced CT of the abdomen and pelvis showing necrotic pancreatic parenchyma (Oct 24, 2024)

CT: Computerized tomography The red arrow shows a necrotizing pancreas with mild fluid. Modified CTSI (Computed Tomography Severity Index): Pancreatic inflammation: Intrinsic pancreatic abnormalities with peripancreatic inflammation (Score: 2). Pancreatic necrosis: Approximately 30–50% non-enhancing parenchyma (Score: 4). Extrapancreatic complications: Presence of peripancreatic fluid collections (Score: 2). Total Modified CTSI Score: 8/10. Severity Grade: Severe Acute Necrotizing Pancreatitis

Figure 4. Abdominal ultrasound showing inflammatory changes in pancreatic parenchyma with fluid collections (Nov 04, 2024)

Figure 5. Abdomen ultrasound showing convalescent phase pancreatitis (Jan 02, 2025)

The red arrow shows the subsiding and resolving phase of pancreatic tissue.