Pancreatitis Aguda Necrótica Infectada con Fistula Enterocutánea

Abstract

Acute pancreatitis is a relatively common disease. With an incidence of 35-80 cases for 100.000 people every year. The clinical results of the AP depend of the presence of necrosis and systematic complications. Among the facts that are associated with the worst prognosis are precisely necrosis, infection and multiple organ failure, which can have a mortality rate as high as 50%. In the case of infected pancreatic necrosis the Guidelines by the International Association of Pancreatology recommended that surgery should be performed between the third and fourth week of the onset of symptoms, there is an association between mortality and time of pancreatic surgery. Necrosectomy within two weeks of admission, is associated with a mortality of 100%, probably because of hemorrhage, in a situation where the obliteration of arterioles is not total, the longer allows areas of necrosis are organized demarcate and thus achieving a better debridement of necrotic tissue in a single surgical procedure, reducing complications and costs. This clinical case corresponds to a male patient of 65 years with personal medical history of hypertension treated with Losartan 100 mg orally QD, Diabetes Mellitus type 2 in treatment with Vildagliptin 50 mg orally QD, habits: Alcohol: every 15 days to arrive drunkenness, until 30 years ago, snuff: from age 18, smoking two cigarettes a day. Who came for presenting abdominal pain high intensity, 7 days evolution, Omeprazole 20 mg orally BID self-medicate with what pain partially stopped, 6 hours ago the problem is exacerbated and nausea is added that arrives vomiting, more apparently blackish deposition, the physical examination reveals slightly tense abdomen, nonpitting, painful on palpation in epigastric and right upper quadrant, decreased bowel sounds, laboratory test results report amylase: 3110 U/L and lipase 786.7 U/L besides neutrophilic leukocytosis, abdominal CAT reports acute pancreatitis type C, so he is interned in ICU, within 72 hours of hospitalization is repeated abdominal CAT scan reporting acute pancreatitis type E, abdominal ultrasound reports: cholelithiasis, RX ray shows bilateral pleural effusion, antibiotic treatment is started, the 5th day refers to patient General Surgery where he remained hospitalized for a period of 15 days after presenting a favorable evolution of its case of pancreatitis, tolerate oral doses, asymptomatic way, it is decided high and surgery on an outpatient basis is planned, the 5th day of patient discharge is hospitalized for abdominal + vomiting + jaundice pain again, ultrasound reporting choledocholithiasis so it is sent to ERCP, it is realized that it failed due to elimination of purulent fluid in the second portion of duodenum and not identify papilla is planned TAC + drain intrapancreatic collection, it reports necrosis >50% + multiple intrapancreatic collections so that no drainage is due to risk of gastric perforation, is transferred to a unit of third level where abdominal sepsis is diagnosed by infected pancreatic necrosis + pancreatic abscess + acute cholecystitis and drainage of pancreatic abscess + necrosectomy + cholecystectomy and the patient is transferred to the ICU of the English Hospital, where it remains hospitalized for three weeks; 4 months later is interned again in the Department of General Surgery for opening enterocutaneous fistula (pancreatic), which is progressing well and achieves the closure of fistula by conservative treatment.