title: Fulminant type of emphysematous pancreatitis has risk of massive hemorrhage.
abstract: Emphysematous pancreatitis (air in the parenchyma) was previously considered an indication for surgery, but some recent studies have reported good clinical outcomes with non-operative management. As a step toward establishing a better treatment strategy, we report a case of fulminant pancreatitis with massive hemorrhage into the emphysematous space. A 75-year-old man was admitted with worsening abdominal pain with obstructive jaundice and renal failure 28 h after the onset. He was diagnosed as having emphysematous pancreatitis with slight pancreatic necrosis. Despite conservative treatment with intensive care, sudden cardiac and respiratory failure occurred, and he died 53 h after onset. The autopsy findings revealed biliary sludge and massive bleeding in the retroperitoneal space around the pancreas, suggesting that temporary obstruction of the bile duct with sludge induced emphysema and the hemorrhage rapidly spread into the broadened emphysematous space. Whereas conservative management has been thought to be appropriate in selected cases of emphysematous pancreatitis, when there is pancreatic emphysema in the early phase, a fulminant course tends to develop. Since there is a risk of massive bleeding into the emphysematous space, endoscopic or invasive drainage performed to collapse the emphysematous space could benefit the outcome.
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Hirotake
authors.initials: H
authors.lastname: Komatsu
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Yoshida
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Hiroki
authors.initials: H
authors.lastname: Hayashi
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Naoaki
authors.initials: N
authors.lastname: Sakata
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Takanori
authors.initials: T
authors.lastname: Morikawa
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Tohru
authors.initials: T
authors.lastname: Onogawa
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Fuyuhiko
authors.initials: F
authors.lastname: Motoi
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Toshiki
authors.initials: T
authors.lastname: Rikiyama
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Yu
authors.initials: Y
authors.lastname: Katayose
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Shinichi
authors.initials: S
authors.lastname: Egawa
authors.affiliation: Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Morihisa
authors.initials: M
authors.lastname: Hirota
authors.affiliation: Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Tooru
authors.initials: T
authors.lastname: Shimosegawa
authors.affiliation: Division of Hepato-Biliary Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan. m_unno@surg1.med.tohoku.ac.jp.
authors.forename: Michiaki
authors.initials: M
authors.lastname: Unno
keywords: Acute necrotizing pancreatitis; Computed tomography (CT); Emphysema; Hemorrhagic shock