# Acute Necrotizing Pancreatitis With Infected Peripancreatic Collections and Upper Gastrointestinal Bleed Managed Via Multimodal Endoscopic Intervention

## TL;DR

A 37-year-old man with severe pancreatitis and infected fluid collections was successfully treated using a combination of endoscopic techniques despite complications like gastrointestinal bleeding.

## Contribution

This case highlights a rare, complex scenario managed through a multimodal endoscopic approach, emphasizing the need for innovative and collaborative care.

## Key findings

- The patient showed significant clinical improvement after three endoscopic necrosectomy sessions.
- Infected necrotic collections were confirmed to contain Klebsiella pneumoniae, Enterobacter, and Enterococcus faecium.
- A lumen-apposing metal stent and endoscopic cystogastrostomy were effective in managing the infected collections.

## Abstract

Acute pancreatitis is a common but potentially life-threatening condition. Although most cases are self-limiting, severe forms such as necrotizing pancreatitis can lead to local complications like pancreatic necrosis or acute necrotic collections (with or without infection), as well as systemic complications such as gastrointestinal bleeding. Management becomes more complex when these complications coexist. A 37-year-old man with no prior comorbidities presented with epigastric pain and vomiting. After imaging, he was found to have choledocholithiasis with acute biliary pancreatitis. After endoscopic retrograde pancreatography and biliary duct stenting, the patient continued to have a fever along with the development of pain, and computerized tomography showed features of necrotizing pancreatitis with evolving fluid collections. Despite conservative treatment, he developed infected necrotic collections requiring endoscopic cystogastrostomy and placement of a lumen-apposing metal stent. A complication of upper GI bleeding occurred during the procedure. Cultures from the drained collection revealed Klebsiella pneumoniae, Enterobacter, and Enterococcus faecium. After three sessions of endoscopic necrosectomy, significant clinical improvement was observed. This case demonstrates a rare yet crucial clinical situation of concomitant infected necrosis and gastrointestinal hemorrhage during the procedure of endoscopic drainage, which necessitated a stepped-up multimodal approach. It underscores the importance of early multidisciplinary decision-making and endoscopic innovation in managing complex pancreatitis.