Papachristou GI, Muddana V, Yadav D, OConnell M, Sanders MK, Slivka A, Whitcomb DC. Using the direct endoscopic necrosectomy technique, a stoma is created endoscopically between the enteric lumen and the necrotic cavity to allow the insertion of an endoscope directly into the cavity, which allows mechanical debridement and lavage. Moreover, the concentration of trypsin is significantly lower in septic shock patients than sepsis patients without shock. The main aim of this article is to present the possible septic complications of acute pancreatitis, its diagnostic and treatment modalities. But those with severe acute pancreatitis can develop serious complications. Open necrosectomy is associated with a high morbidity (34%-95%) and mortality ranges from 6% to 25%[25]. Acute. Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre. The pancreas is a gland. Accessed Nov. 19, 2022. During the first 1-2 wk, a pro-inflammatory response occurs, which results in systemic inflammatory response syndrome (SIRS), a sterile response in which sepsis or infection rarely occurs. nausea and vomiting,; abdominal tenderness, and; fever. 2003;10(6):419-24. doi: 10.1007/s00534-002-0811-x. Serum thiamine concentration and oxidative stress as predictors of mortality in patients with septic shock. Surgical management of acute necrotizing pancreatitis: a 13-year experience and a systematic review. Therefore, the current recommendation is to delay the surgery as late as possible after the onset of pancreatitis until the necrotic process has stopped expanding and when there is a clear demarcation between viable and nonviable tissues, so that the infected necrosis has become walled off or organized[9,69,86]. Always see your healthcare provider to be sure. I. However, few experimental and human studies have suggested that other mechanisms might also be involved such as cell apoptosis[28,29], increased release of nitric oxide by the endothelial cells[30], platelets activation[31], ischemia - reperfusion phenomenon[32], elevated triglyceride levels and the development of biliary sludge[33]. Early morbidity and mortality are the result of activation of mediators with failure of circulation and other organ systems. How to Lower Your Risk of Future Pancreatitis Attacks Only a few studies have focused on the exocrine pancreatic dysfunction in the subgroup of critically-ill patients with septic shock[23-25]. Bile can solidify in your gallbladder if you have high blood cholesterol levels. Catheters often need to remain in place for several weeks and sometimes months; hence, close follow-up is required[3,49,72]. In 1998, Freeny et al[75] first described a consecutive series of patients who had infected pancreatic necrosis and who were treated primarily with imaging-guided PCD, as an alternative to primary surgical necrosectomy. He or she will give you a physical exam. 2007 Jul-Aug;102(4):383-8. However, most of these studies have concluded that this elevation is not always due to pancreatic insults[16-18]. CLASSIFICATION According to the Atlanta classification, acute pancreatitis can be divided into two broad categories [ 7 ]: Interstitial edematous acute pancreatitis, which is characterized by acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis. Hence, other markers have been used to assess the exocrine pancreatic dysfunction in critically-ill patients. Other factors, such as the activation of the phagocytic cells and the production of nitric oxide by the endothelial cells, have been shown to aggravate the oxidative stress[57]. Also write down any new instructions your provider gives you. Infection is usually recorded in the second week of the disease in 24 % and in 71 % during the fourth week of the disease. Accessibility Bring someone with you to help you ask questions and remember what your provider tells you. Comparison of BISAP, Ransons, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Frequent, forceful bowel movements. Accessed Nov. 19, 2022. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. If the SIRS is severe, then proinflammatory mediators can cause early multiple (respiratory, cardiovascular, renal, and hepatic) organ failure. The pancreas lies behind your stomach on the left side of your belly. Sepsis is a serious condition in which the body responds improperly to an infection. the contents by NLM or the National Institutes of Health. Although no universally accepted treatment algorithm exists, the step-up approach using close monitoring, percutaneous or endoscopic drainage, followed by minimally invasive video-assisted retroperitoneal debridement has demonstrated to produce superior outcomes to traditional open necrosectomy and may be considered as the reference standard intervention for this disorder. Whether specific treatment should be considered to avoid malnutrition in these patients need to be investigated further. https//www.uptodate.com/contents/search. You may have some blood tests done. The advantages of EUS-guided endoscopic drainage include the ability to visualize and determine the optimal access into the collection, to avoid intervening blood vessels, to assess the contents of the cavity, and to visualize bleeding into the collection and other complications during and immediately after the procedure[25]. Ljungdahl M, Rasmussen I, Haglund U. Intestinal blood flow and intramucosal pH in experimental peritonitis. FOIA Sharma VK, Howden CW. pancreas. It is very important to stop smoking and drinking or the pancreatitis will usually happen again and worsen. Management of acute pancreatitis - UpToDate Fundamental and intensive care of acute pancreatitis. Stanten R, Frey CF. Q&A: Pancreatic cancer risk, symptoms and treatment. If this approach fails, minimal invasive surgery is employed, with open surgery being reserved for those patients who do not respond to less invasive techniques[3,13,18,20,22-24,85,111]. Before Vege SS, Fletcher JG, Talukdar R, Sarr MG. Peripancreatic collections in acute pancreatitis: correlation between computerized tomography and operative findings. High-risk for ESBL species: may consider meropenem instead. Sepsis and septic shock. Surgical intervention is postponed for as long as possible so that the infected collection may become encapsulated[3,22] and is performed when the patients condition does not improve or if it deteriorates. Hence, epidemiological data regarding the pancreatic function impairment in this group of patient is lacking. Implications for treatment. Wang S, Ma L, Zhuang Y, Jiang B, Zhang X. Prognostic categorization of intensive care septic patients. When the damage is severe, it can lead to death. Although no universally accepted treatment algorithm exists, the step-up approach using close monitoring, percutaneous or endoscopic drainage, followed by minimally invasive video-assisted retroperitoneal debridement has been shown to produce superior outcomes to traditional open necrosectomy and may be considered as the reference standard intervention for this disorder. Physical and radiologic scoring systems have been developed with the aim of predicting which patients will have a severe clinical course and which patients might recover without major physiologic insult[32,34]. Therefore, for the management of such complex disease entities, a multidisciplinary team approach is essential, and the final selection of the optimal treatment of SAP will depend on multiple factors, including the expertise available at a given center, specific patient characteristics and risk assessment findings. Anis Chaari, Karim Abdel Hakim, Kamel Bousselmi, Mahmoud Etman, Mohamed El Bahr, Ahmed El Saka, Eman Hamza, Mohamed Ismail, Elsayed Mahmoud Khalil, Vipin Kauts, William Francis Casey, Department of Intensive Care, King Hamed University Hospital, Al Muharaq 24343, Bahrain. Dickson AP, Imrie CW. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Concomitantly, the systemic blood flow is increased in the gallbladder and the colon whereas it is markedly decreased in the pancreas. Similarly, hypoxic liver injury in patients with septic shock has been reported to be associated with a mortality as high as 50%[11,12]. The https:// ensures that you are connecting to the Most people recover from mild sepsis, but the mortality rate for septic shock is about 30% to 40%. Increase in levels of pancreatic enzymes does not significantly affect the outcome. Unable to load your collection due to an error, Unable to load your delegates due to an error. Inclusion in an NLM database does not imply endorsement of, or agreement with, government site. The German Study Group on Acute Biliary Pancreatitis. Sepsis: Diagnosis and Management | AAFP Acute necrotizing pancreatitis, Infection, Sepsis, Drainage, Gastrointestinal endoscopy. https://www.cdc.gov/sepsis/prevention/index. Timing and impact of infections in acute pancreatitis. Ann Ital Chir. Therefore, to minimize the risk of complications, such as puncturing adjacent structures, bleeding, and perforation, EUS is increasingly used to perform endoscopic drainage. Minimally invasive step-up approach versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. Honore PM, Jacobs R, Hendrickx I, Bagshaw SM, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Abdominal pain (sometimes described as stomach pain) is the main symptom of pancreatitis, but other symptoms can include. Font MD, et al. The smaller lumen of the drains is used for the inflow of the lavage, and the larger lumen is used for the outflow. sharing sensitive information, make sure youre on a federal Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. However, the extent of pancreatic necrosis is not fixed and may progress as the disease evolves during the first 2 wk[25]. Image-guided PCD of collections in and around the pancreas in patients with acute necrotizing pancreatitis is an important therapeutic option either on its own or as an adjunct to surgery. Pathogenesis and prevention of early pancreatic infection in experimental acute necrotizing pancreatitis. Devices that go in the body, such as catheters in the vein, called intravenous, or breathing tubes. Doctor N, Philip S, Gandhi V, Hussain M, Barreto SG. An observational CT study. Beger HG, Bchler M, Bittner R, Oettinger W, Block S, Nevalainen T. Necrosectomy and postoperative local lavage in patients with necrotizing pancreatitis: results of a prospective clinical trial. Evaluation and management of suspected sepsis and septic shock in adults. Ruetten H, Southan GJ, Abate A, Thiemermann C. Attenuation of endotoxin-induced multiple organ dysfunction by 1-amino-2-hydroxy-guanidine, a potent inhibitor of inducible nitric oxide synthase. Besselink MG. However, imaging test rarely reveal significant pancreatic damage. WON can be located intrapancreatically or extrapancreatically. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). More than 80% of deaths associated with AP are attributed to septic complications as a consequence of bacterial infection in pancreatic necrosis[49]. Check out these best-sellers and special offers on books and newsletters fromMayo Clinic Press. Severe acute pancreatitis (SAP), which is the most serious type of this disorder, is associated with high morbidity and mortality. Effect of PGE1 on altered distribution of regional blood flows in hyperdynamic sepsis. A: Large fluid collection and pancreatic necroses before drainage; B: Catheter in the peripancreatic fluid collection; C: Massive pancreatic necroses with secondary fluid collection. Magnetic resonance imaging (MRI) is a good alternative to CT for detecting parenchymal necrosis; magnetic resonance cholangiopancreatography (MRCP) may replace ERCP in the diagnostic evaluation of the pancreatic duct (PD)[47,50-52]. Windsor JA. The definition of exocrine pancreatic insufficiency in their study was based on decreased fecal elastase-1 concentration (< 200 mcg/g). Sepsis is very dangerous. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). The recent trend in managing symptomatic PPC has been toward less invasive approaches, such as endoscopic and image-guided PCD[83,102-104,106]. Traditionally, surgery was the only treatment option for symptomatic PPC[83,105]. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. This includes bacterial, viral or fungal infections. Another example is pancreatitis necrosisdeath of pancreatic tissuewhich can lead to sepsis. Moossa AR. HHS Vulnerability Disclosure, Help Several randomized controlled trials offer evidence for the effectiveness of prophylactic antibiotics in reducing septic complications and mortality of patients with necrotizing pancreatitis[62,63]. Necrotic (dead) tissue is a feast for roaming bacteria. Moreover, the advantages of PCD include widespread availability, access by transperitoneal and retroperitoneal approaches to the left and right sides of the abdomen and pelvis, the ability to insert multiple catheters (Figure (Figure2),2), and the ability to flush catheters between procedures without general anesthesia and with fewer traumas, simultaneously performing vigorous irrigation with similar effects as performed surgically[3,73,74]. Will U, Wegener C, Graf KI, Wanzar I, Manger T, Meyer F. Differential treatment and early outcome in the interventional endoscopic management of pancreatic pseudocysts in 27 patients. Ferkau A, Gillmann HJ, Mischke R, Calmer S, Ecklebe S, Abid M, Minde JW, Echtermeyer F, Theilmeier G. Infection-associated platelet dysfunction of canine platelets detected in a flow chamber model. Treatment for each case of pancreatitis depends on the severity of symptoms. The incidence and prognosis of body wall ecchymosis in acute pancreatitis. Although the most widely accepted hypothesis used to explain pancreatic dysfunction in patients with septic shock is pancreatic ischemia, significant pancreatic injury has also been reported in normotensive sepsis model. Symptoms specific to the type of infection, such as painful urination from a urinary tract infection or worsening cough from pneumonia. Pezzilli et al[23] have reported that amylase and lipase levels are significantly increased in patients with septic shock in comparison to a control group. Primum non nocere! Pancreatitis may be sudden (acute) or ongoing (chronic). Rattner DW, Gu ZY, Vlahakes GJ, Warshaw AL. Pivotal role of glutathione depletion in plasma-induced endothelial oxidative stress during sepsis. Los clculos biliares, que se producen en la vescula biliar, pueden salirse de la vescula biliar y obstruirla, detener el trayecto de las enzimas pancreticas hacia el intestino delgado y obligarlas a retroceder al pncreas nuevamente. High levels of fat particles (triglycerides) in the blood, Certain medicines, such as estrogens, steroids, and thiazide diuretics, Infections, such as mumps, hepatitis A or B, or salmonella, Severe belly pain that may spread to your back or chest (it may feel worse after you eat), Swelling and feeling sore or tender in your upper belly, Yellowing of the skin and eyes (jaundice), Will be given pain medicine and medicines that fight bacterial infections (antibiotics). A Cochrane meta-analysis concluded that antibiotic prophylaxis is not protective in SAP[66]. Acute pancreatitis: the role of imaging and interventional radiology. Pomerantz WJ, et al. Hiltebrand LB, Krejci V, Banic A, Erni D, Wheatley AM, Sigurdsson GH. McKay CJ, Imrie CW. If the patients condition improves (in approximately 35% of cases)[22], after percutaneous or endoscopic approach, no surgical debridement is performed. Tribl et al[25] have reported similar results as they found that the concentration of amylase and chymotrypsin in the duodenal juice is significantly lower in patients with sepsis or septic shock than in healthy volunteers. Three catheters inserted percutaneously into the abscess collections formed during the clinical course of necrotizing pancreatitis. Abdominal tenderness or bloating (distention) Blood in your stool. Neoptolemos JP, Shaw DE, Carr-Locke DL. The role of prophylactic antifungal agents has not been fully defined[54,64]. For patients with infected necrosis, there is convincing evidence that the early surgical intervention (before 3 wk) for pancreatic necrosis could result in a worse prognosis compared to patients where surgery is delayed. Author contributions: Zerem E was the sole contributor to this paper. Low serum calcium concentrations are most often caused by disorders of PTH or vitamin D. Other causes of hypocalcemia include disorders that result in a . Each access route has its own advantages and disadvantages, such as ease of access, ability to address multiple collections and risk of collateral injury. Inclusion in an NLM database does not imply endorsement of, or agreement with, A condition that requires treatment with corticosteroids, which can lower immune response. Pelaez-Luna M, Vege SS, Petersen BT, Chari ST, Clain JE, Levy MJ, Pearson RK, Topazian MD, Farnell MB, Kendrick ML, et al. Federal government websites often end in .gov or .mil. Mayo Clinic does not endorse companies or products. In fact, a temporary ischemia for 40 min has been shown to be sufficient to cause significant pancreatic injury on histological examination, presenting mainly as peripheral necrosis of the lobules[37]. Bennett JE, et al. Long-term results and quality of life of patients undergoing sequential surgical treatment for severe acute pancreatitis complicated by infected pancreatic necrosis. World Journal of Gastrointestinal Oncology. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Symptoms of acute pancreatitis. Several conditions must be met to achieve the complete obliteration of the cyst cavity. Symptoms of sepsis are not specific. Additionally, surgical necrosectomy carries a high risk of bleeding from vessels in the necrotized tissue during or immediately after the intervention. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Many recommendations have been made regarding SAP management and its complications. Nealon WH, Walser E. Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas. SAP runs a biphasic course. sharing sensitive information, make sure youre on a federal Wendel M, Paul R, Heller AR. Sepsis and septic shock Basics of diagnosis, pathophysiology and clinical decision making. Current concepts. The Balthazars CT severity index (CTSI)[48] is commonly used to stratify the severity of the disease and to predict mortality (Table (Table11). The individual components of the step-up approach may be subject to improvement. The management of SAP varies with the severity and depends on the type of complication that requires treatment. Segal D, Mortele KJ, Banks PA, Silverman SG. Balthazar EJ. If the Seldinger technique is used, then the catheter tract should be sequentially dilated over a guidewire. Computer tomography indeks of illness severity for acute pancreatitis[48]. Fever. This raises the question: Which marker can be considered as a reliable test to assess the pancreatic dysfunction? Necrotizing pancreatitis can result from extreme cases of acute pancreatitis. It does 2 main things: Pancreatitis may be sudden (acute) or ongoing (chronic). As a library, NLM provides access to scientific literature. trauma. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. Depending on the operator experience, tandem trocar technique or Seldinger technique can be used. Ultrasound appearance of infected pancreatic necrosis before and after the treatment of acute pancreatitis. The primary symptom of pancreatitis is upper abdominal pain that may spread to your back. Bai X, Yu W, Ji W, Lin Z, Tan S, Duan K, Dong Y, Xu L, Li N. Early versus delayed administration of norepinephrine in patients with septic shock. Management of acute pancreatitis: from surgery to interventional intensive care. Gallstones block the pancreatic duct so the enzymes cant get out of the pancreas. Baron TH, Thaggard WG, Morgan DE, Stanley RJ. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Signs and symptoms of acute intestinal ischemia typically include: Sudden belly (abdominal) pain that may be mild, moderate or severe. Have to avoid alcohol (if your pancreatitis is caused by alcohol abuse), Need enzyme supplements to help digest your food, Need to eat small high-protein, low-fat meals. 2021; https://doi.org/10.1007/s11739-021-02735-7. Imaging of acute pancreatitis and its complications. Severe Acute Pancreatitis Causing Sepsis - Glynns If we combine this information with your protected health information, we will treat all of that information as protected health information and will only use or disclose that information as set forth in our notice of privacy practices. In 2001, Horvath et al[93] described the video-assisted retroperitoneal debridement (VARD) approach, using a 4-5 cm retroperitoneal incision and regular laparoscopic equipment for removing the infected necrosis. Fever. Peritonitis - Symptoms and causes - Mayo Clinic It may be sudden (acute) or ongoing (chronic). In people with severe pancreatitis, life-threatening symptoms can occur such as kidney failure. ERCP, MRCP and wirsungraphy by using CT may be utilized in the diagnostic evaluation of PD disruption[1,47,50-52,54]. Practice guidelines in acute pancreatitis. Currently, there are various open surgical approaches for removing the pancreatic necroses. Walser EM, Nealon WH, Marroquin S, Raza S, Hernandez JA, Vasek J. Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration. Who is at risk? Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS. ( No need for vancomycin.) Ball CG, Correa-Gallego C, Howard TJ, Zyromski NJ, House MG, Pitt HA, Nakeeb A, Schmidt CM, Akisik F, Lillemoe KD. Tissue oxygenation in low flow states and during hypoxemia. Necrotizing Pancreatitis | Cedars-Sinai In: A Rational Approach to Clinical Infectious Diseases: A Manual for House Officers and Other Non-Infectious Diseases Clinicians. Isaji S, Mizuno S, Tabata M, Yamagiwa K, Yokoi H, Uemoto S. J Hepatobiliary Pancreat Surg. Pancreatic necrosis develops early in the course of SAP and is usually well established by 96 hours after the onset of clinical symptoms. Having gallstones and drinking a lot of alcohol are the two most common causes of pancreatitis. that help stratify the severity of AP. In fact, only a few studies, most of them with a small number of patients, have investigated pancreatic dysfunction in critically-ill patients[19,21,23-25,44]. However, acute pancreatitis (AP) is a complex disease; despite the existence of several criteria, it is not easy to predict its subsequent course because often in patients with the same initial clinical and radiological scores, the clinical course of the disease may vary. Bethesda, MD 20894, Web Policies Heavy drinking. Before The limitations of EUS are the inconsistent availability of skilled endosonographers with endoscopic and imaging skills, a potential for adverse events in critically ill patients, and a tendency to overestimate the necrotic debris content of pancreatic fluid collections[25,49]. Major change in mental status, such as extreme confusion. The pancreas is particularly sensitive to hypotension. SAP should be managed in an intensive care unit that is equipped to apply intensive monitoring and systemic support, including supportive care, prompt fluid resuscitation to maintain circulation volume and prevent electrolyte imbalance, nutritional supplements, analgesics, oxygen supplementation, mechanical ventilation, as well as monitoring for respiratory, cardiovascular and renal insufficiency and their early correction[3,7,53-55]. Its role in the assessment of choledocholithiasis is to aid in triaging patients who require therapeutic endoscopic retrograde cholangiopancreatography (ERCP), thus eliminating potential complications that might be associated with diagnostic ERCP. The incidence of secondary infection and sepsis correlates with the extent of pancreatic necrosis. Endoscopic ultrasound (EUS) is a useful modality for evaluating patients with AP. It does 2 main things: It makes enzymes and sends them into your small intestine. ; Symptoms and signs of pancreatitis may range from mild to severe and even . Steinberg W, Tenner S. Acute pancreatitis. Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, Carter R, Di Magno E, Banks PA, Whitcomb DC, et al. Forrester JD. Intestinal ischemia - Symptoms and causes - Mayo Clinic Wray GM, Hinds CJ, Thiemermann C. Effects of inhibitors of poly(ADP-ribose) synthetase activity on hypotension and multiple organ dysfunction caused by endotoxin. Pancreatitis: Symptoms, Causes, Diagnosis, Treatments, Tests - WebMD Zerem E. Reply to: draining sterile fluid collections in acute pancreatitis? To provide you with the most relevant and helpful information, and understand which information is beneficial, we may combine your email and website usage information with other information we have about you. Occasionally, emobilization can be performed using angiography, which may stop the bleeding. FOIA The .gov means its official. Due to its ability to characterize pancreatic and peripancreatic collections or abscesses as partial or full fluid in consistency, lack of radiation, ability of MRCP to detect bile duct stones, and ability to demonstrate the presence of disconnected PD, MRI has a fundamental impact on the course of additional management. The aim of this review is to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Peripancreatic fluid collections are common and are termed acute fluid collections if present for less than 4 wk, after which time they are referred to as pancreatic pseudocysts (PPCs). Horvath K, Freeny P, Escallon J, Heagerty P, Comstock B, Glickerman DJ, Bulger E, Sinanan M, Langdale L, Kolokythas O, et al. Nieuwenhuijs VB, Besselink MG, van Minnen LP, Gooszen HG. official website and that any information you provide is encrypted Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Damage to the Acinar cells consists of nuclear fragmentation, abnormal cytoplasmic vacuoles and cellular swelling[28,29,52,53]. Besselink MG, Verwer TJ, Schoenmaeckers EJ, Buskens E, Ridwan BU, Visser MR, Nieuwenhuijs VB, Gooszen HG. However, with drainage problems, monitoring, catheter manipulation and the analysis of cystic content are difficult or impossible to perform endoscopically, unlike with PCD approach[83]. Hemorrhage into the pancreatic bed or adjacent retroperitoneum is usually a consequence of gastrointestinal bleeding, which occurs due to gastroduodenitis, bleeding peptic ulcer and pancreatitis-induced enzymatic damage to the adjacent vasculature, such as the splenic, renal or gastroduodenal arteries and the development of an aneurysm in one of these arteries[38,45].
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