Acute necrotizing emphysematous pancreatitis with air in the wirsung duct mimicking duodenal perforation: a case report

ABSTRACT

A 74-year old hemodynamically unstable woman with an acute abdomen presented at the emergency department. Laboratory findings indicated leukocytosis (21000/µl), increased CRP (300mg/l) and lipase (3792kU/l). CT abdomen without contrast showed multiple air pockets in and around the pancreas body, retroperitoneal along the duodenum as well as air in the Wirsung duct. A duodenal perforation was suspected. On explorative laparoscopy however no immediate sign of perforation was seen despite infusion of methylene blue through a nasogastric catheter. Further exploration showed a necrotizing exudative pancreatitis. Because of perioperative hemodynamic instability, further invasive actions were put off. Acute necrotizing emphysematous pancreatitis is a severe pathology with a high mortality (25-70%). Air in the Wirsung duct is rarely described in literature and so far an underlying explanation remains unclear. In this case gas-forming organisms may have entered the pancreas through haematogenous or lymphatic spread, as well as directly through the ampulla or by transmural passage from the transverse colon

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