Acute Abdomen Associated with Retroperitoneal Gas

A 50-year old male presented to the emergency department with abdominal pain for 3 days associated with non- bilious vomiting and constipation. There was a history of high-grade fever for 1 day. There was a history of such episodes in the past. He was a chronic smoker and alcoholic. On examination, his pulse rate was found to be 110/min, blood pressure (BP) was 90/70 mmHg and there was no icterus. There was diffuse tenderness and guarding all over the abdomen, and bowel sounds were absent. His laboratory investigations revealed hemoglobin (Hb) 8g%, total leukocyte count 18,000/mm³, bilirubin 1.1mg%, urea 18mg%, and amylase 1218 IU. Abdominal X-ray did not reveal any pneumoperitoneum. Abdominal sonography showed dilated bowel loops with minimal inter-loop fluid, normally distended gall bladder, and obscured retroperitoneum. Contrast-enhanced computerized tomographic (CT) scan of the abdomen was carried out, which showed a bulky pancreas with non-enhancing areas in the body and tail. Extensive gas, and a few collections were seen in the peripancreatic region [Figure 1].

Figure 1.

CT image showing retroperitoneal gas

QUESTIONS

Q1. What is the diagnosis?

Q2. How would you manage this condition?

ANSWERS

Emphysematous pancreatitis

Emphysematous pancreatitis is a dreaded life-threatening complication of acute pancreatitis and is characterized by gas formation within or around the pancreas.[1,2]

Gas-forming organisms from the bowel may enter the pancreas by various means to cause emphysematous pancreatitis. Common routes of entry include blood and lymphatic spread, as well as direct invasion from reflux through the ampulla, or transmural passage from the adjacent transverse colon. Besides infection by gas-forming bacteria such as Clostridium, Escherichia coli, Staphylococcus, Streptococcus, Candida, Klebsiella, and Pseudomonas, other possible sources include enteric fistula formation, bland tissue infarction, and reflux from the adjacent hollow viscus. Gas should be differentiated from atmospheric air introduced at recent surgery or instrumentation. Gas associated with infection is generally thought to consist of carbon dioxide and nitrogen secondary to fermentation of glucose by some species of bacteria.

Management of emphysematous pancreatitis consists of fluid resuscitation and anti-microbial therapy to control septic shock. Depending on the clinical condition, surgical debridement or percutaneous drainage may also be possible. Omezzine et al.,[3] and Wig et al.,[1] described the utility of computed tomography as the imaging modality of choice for diagnosis of acute emphysematous pancreatitis. It is both highly sensitive and specific in the detection of abnormal gas, and reliable in depicting the anatomical location and extent of the gas.