Two's a Charm: Endoscopic Therapy of Multiple Pancreatic Pseudocysts.

Pancreatic pseudocysts commonly complicate acute pancreatitis. They can evolve either asymptomatically or with important symptoms. Treatment can be surgical, endoscopic, or percutaneous. The authors present a case report of a 78-year-old man who developed symptoms of an acute abdomen during hospitalization. A CT scan showed two pancreatic pseudocysts (diameters 10 cm and 7.5 cm) that were successfully drained endoscopically. Multiple pancreatic pseudocysts can be treated successfully via an endoscopic approach.

An Unlikely Cause of a Blunt Pancreatic Injury.

We report the case of a 17-year-old male football player with blunt abdominal trauma. Careful evaluation, including computed tomography and laboratory, revealed a pancreatic body laceration. Pancreatic injuries are relatively uncommon and associated with significant morbidity and mortality and require early diagnosis for optimal management and outcome.

Management of multi drug resistant endogenous Klebsiella pneumoniae endophthalmitis with intravitreal and systemic colistin.

We report a case of a 35-year-old male with a pancreatic pseudocyst, who developed bilateral endogenous endophthalmitis, 4 days after surgical drainage of the pseudocyst. Bacterial cultures of the pancreatic drain fluid and the vitreous tap showed the growth of Klebsiella pneumoniae. The cultured organism was resistant to all the tested antibiotics except colistin. Intravenous colistin was instituted and three injections of intravitreal colistin were given in the left eye of the patient. Complete resolution of infection was seen and visual acuity of 6/6 was regained in both eyes, which was maintained at 4-month follow-up.

Fungal Infections in Patients With Infected Pancreatic Necrosis and Pseudocysts: Risk Factors and Outcome.

OBJECTIVES: Fungal infections in patients with acute pancreatitis are common and potentially life threatening. Data on fungal pancreatic infections are inconsistent. Therefore, the aim of this study was to identify risk factors for fungal infection and to determine their impact on survival. METHODS: This was a retrospective analysis of pathogen spectrum and outcome of infected pancreatic necrosis or pseudocysts from 3 German hospitals from 2002 to 2016. RESULTS: A total of 187 fine-needle aspirations were performed in 113 patients. Fungal pancreatic infections, predominantly caused by Candida species, were identified in 52 patients (46%). Antibiotic treatment before fine-needle aspiration (84.6% vs 49.2%, P = 0.003) and the duration of therapy (9 vs 2 days, P = 0.024) identified patients at an increased risk of fungal infection. Patients with fungal pancreatic infections had a longer hospital stay (34 vs 14 days, P < 0.001), received intensive care treatment more often (55.8% vs 27.9%, P = 0.002), and had a lower 365-day survival (78.4 [SE, 6.6%] vs 95.0 [SE, 2.0%], P = 0.035) than patients with bacterial pancreatic infections only. CONCLUSIONS: Fungal infections are common in patients with infected pancreatic necrosis and pseudocysts and indicate patients with a higher risk of mortality in the long term.

Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails To Treat a Patient with a Disseminated Resistant Acinetobacter baumannii Infection.

Widespread antibiotic use in clinical medicine and the livestock industry has contributed to the global spread of multidrug-resistant (MDR) bacterial pathogens, including Acinetobacter baumannii We report on a method used to produce a personalized bacteriophage-based therapeutic treatment for a 68-year-old diabetic patient with necrotizing pancreatitis complicated by an MDR A. baumannii infection. Despite multiple antibiotic courses and efforts at percutaneous drainage of a pancreatic pseudocyst, the patient deteriorated over a 4-month period. In the absence of effective antibiotics, two laboratories identified nine different bacteriophages with lytic activity for an A. baumannii isolate from the patient. Administration of these bacteriophages intravenously and percutaneously into the abscess cavities was associated with reversal of the patient's downward clinical trajectory, clearance of the A. baumannii infection, and a return to health. The outcome of this case suggests that the methods described here for the production of bacteriophage therapeutics could be applied to similar cases and that more concerted efforts to investigate the use of therapeutic bacteriophages for MDR bacterial infections are warranted.

Management of pancreatic fluid collections: A comprehensive review of the literature.

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.

Microbiologic analysis of peri-pancreatic fluid collected during EUS in patients with pancreatitis: impact on antibiotic therapy.

BACKGROUND: Pancreatitis is a potentially life-threatening condition frequently accompanied by peri-pancreatic fluid collections (PPFC), such as pseudocysts or pancreatic necrosis. Aspiration of PPFCs during EUS interventions for microbiologic analysis is still rarely performed in clinical routine. OBJECTIVE: To evaluate the role of routine microbiologic analysis of PPFCs and its impact on antibiotic therapy in patients with pancreatitis. DESIGN: Prospective, observational, multicenter study. SETTING: Four treatment centers. PATIENTS: A total of 44 consecutive patients who presented for endoscopic treatment of PPFCs were included. INTERVENTION: Concomitantly, PPFC during intervention and concomitant blood cultures were obtained. MAIN OUTCOME MEASUREMENTS: Microbiologic examination of PPFCs and blood samples. RESULTS: Colonization of PPFCs was found in 59% of PPFC cultures, whereas all but 2 concomitant blood cultures showed no microbial growth. Risk factors for a colonization were the presence of necrosis (P = .006), acute pancreatitis (P = .033), leukocytosis (P = .001), elevated C-reactive protein levels (P = .003), fever (P = .02), turbid material (P = .031), and longer hospital stay (P = .003). In 23 patients with fluid colonization despite empiric antibiotic therapy, the treatment had to be adjusted in 18 patients (78%) according to the observed antibiotic susceptibility profile. LIMITATIONS: Contamination cannot be totally excluded. CONCLUSION: The microbiologic colonization of PPFCs in patients with pancreatitis is common. Only the direct microbiologic analysis of PPFCs, but not of blood cultures, is useful to optimize an effective antibiotic therapy in patients with pancreatitis.

Acute pancreatitis complicated by infected pseudocyst in a child with pancreas divisum.

INTRODUCTION: Acute pancreatitis occurs less frequently in children than in adults, although it seems to be more common than has been considered in the past. There are several causes of pancreatitis in childhood: trauma, infections or structural gland anomalies as pancreas divisum. CASE PRESENTATION: We report a case of non-traumatic severe acute pancreatitis in a 8-year-old girl with pancreas divisum, complicated by a rapid formation of a large infected pseudocyst which required a surgical internal drainage by a Roux-en-Y cystojejunostomy. DISCUSSION: Pancreas divisum is the most common congenital anomaly of the pancreas with an incidence of 3-10% of population, and its role in causing acute or recurrent pancreatitis is still controversial. There are only sporadic observations of acute pancreatitis complicated by pseudocyst in children with pancreatic anomalies and its treatment is not standardized. Three different approaches have been described to treat a pancreatic pseudocyst: percutaneous, endoscopic or surgical drainage. We decided to perform a pseudocyst-jejunostomy because of the disease severity. CONCLUSION: Even in the non-invasive era, the surgical approach to treat a large complicated pseudocysts in children still represents a safe and feasible approach in emergencies as acute abdomen, bleeding or sepsis. Complications of percutaneous and endoscopic drainages are avoided and long term results are excellent. KEY WORDS: Acute pancreatitis, Pancreas divisum, Pancreatic pseudocyst.

[Pancreatic pseudocyst infection caused by Haemophilus parainfluenzae. Report of one case]. / Infección de pseudoquiste pancreático por Haemophilus parainfluenzae. Caso clínico.

We report a 48-year-old male admitted to hospital due to a severe alcoholic pancreatitis. At four weeks of evolution of the acute episode, an abdominal CAT scan showed a fluid collection of 20 cm diameter located in the pancreatic tail and 2 small collections in the head. The patient received several antimicrobials and during the seventh week of evolution, while receiving vancomycin, presented fever. A fine needle aspiration of the cyst revealed the presence of Haemophilus parainfluenzae biotype VIII. The patient was treated with amoxicillin-clavulanic acid and a laparoscopic cysto-gastrostomy, with a good clinical response.

The microbiology of secondary and postoperative pancreatic infections: implications for antimicrobial management.

HYPOTHESIS: We reviewed our experience with secondary pancreatic infections with a focus on preemptive intervention and the potential alteration of the recovered microbial flora. The pathogens associated with postoperative pancreatic infections were analyzed with respect to nonenteric organisms, if any, that were recovered. We hypothesized that our findings might alter the antimicrobial management of these patients. DESIGN: Retrospective review. SETTING: Hospitals affiliated with the University of Tennessee Health Science Center, Memphis. PATIENTS: Patients developing secondary and postoperative pancreatic infections following severe acute pancreatitis. METHODS: Factors examined relative to secondary pancreatitis included preoperative antibiotic use and antecedent extrapancreatic infections potentially implicated in seeding the pancreatic bed. Patients who had elective resection received 24 to 48 hours of antibiotic prophylaxis. RESULTS: Twenty-two patients required surgery for secondary infections following severe acute pancreatitis, with 29 pathogenic isolates being recovered. Of these 22 patients, 14 received vancomycin hydrochloride prior to surgical intervention. Of those 14 patients, 6 had isolates recovered at the time of surgery that were positive for Enterococcus faecalis and 5 of these isolates were vancomycin resistant. Eight of the 22 patients received antifungal prophylaxis with no fungi recovered from intraoperative culture. However, 2 of the 14 patients who did not receive empiric therapy had isolates that were positive for fungi. Five patients who required an urgent operation for sepsis had pathogenic isolates that were similar to those recovered from central lines. Postoperative infections occurred in 40 of 225 patients (17.8%) who had an elective pancreatic resection, with 72 pathogenic isolates being recovered. Of these 40 patients, 22 (55.0%) had polymicrobial infections. Of the 72 pathogenic isolates recovered from patients, 34 (47.2%) were gram-positive organisms, 15 (20.8%) were fungal organisms, and 17 (23.6%) were drug-resistant bacteria. CONCLUSIONS: Prolonged vancomycin use in patients with severe acute pancreatitis is associated with the acquisition of vancomycin-resistant enterococci. Empiric antifungal therapy may reduce the incidence of secondary fungal pancreatic infections. Systemic bloodstream infections at extrapancreatic sites can lead to seeding of pancreatic pseudocysts. Postoperative infections frequently include gram-positive, fungal, and drug-resistant organisms, and empiric therapy directed at these pathogens should be utilized until definitive culture results are obtained.

Two unique presentations of Achromobacter xylosoxidans infections in clinical settings.

Two rare and unique infections of Achromobacter xylosoxidans are described. The first case is a novel presentation of acute necrotising pancreatitis leading to a pancreatic pseudocyst, which was treated successfully in an immunocompetent male. The second case describes a local wound infection of metastatic ductal carcinoma of the breast; the patient consequently succumbed from a pre-existing co-morbid condition. Vigilant and efficient microbiological workup and surveillance are needed to diagnose infections by this rare pathogen in clinical settings.