Complexities in Alcoholic Necrotizing Pancreatitis: A Case Report of Severe Vascular and Infectious Complications

Acute pancreatitis (AP) incidence has been increasing, with an annual incidence of approximately 5 to 40 cases per 100,000.1 Several complications occur with AP, including splanchnic vein thrombosis (SVT), pseudocyst, and pseudoaneurysm (PSA). Moreover, 15-20% of patients develop necrotizing pancreatitis (NP) following an episode of AP with a mortality rate of up to 32%,2 which can be further complicated by infected necrosis in up to one-third of patients.2 Hemorrhage is estimated to occur in less than 6% of patients with NP by pseudoaneurysm.3 The endoscopic step-up approach is the standard treatment for walled-off necrosis, whereas alternative therapy includes percutaneous drainage followed by minimally invasive surgery.4 Although antibiotic prophylaxis in AP has been inconclusive, early initiation of antibiotic therapy has improved treatment outcomes by reducing infection-related morbidity and mortality by treating infected NP.5 In this case report, we present a complex case of a patient suffering from recurrent alcoholic pancreatitis leading to an infected NP requiring numerous endoscopic and interventional radiology procedures. The hospitalization was prolonged with various complications, not limited to methicillin-sensitive Staphylococcus aureus (MSSA) with vancomycin-resistant Enterococcus (VRE) peritonitis, portal vein thrombosis, and splenic artery pseudoaneurysm bleeding. We highlight the need for prophylactic and early initiation of antibiotics in NP, the risks versus benefits of endoscopic versus surgical procedures, discuss the need for anticoagulation (therapeutic versus prophylactic) for SVT and venous thromboembolism (VTE) in the setting of pancreatic hemorrhage, and the importance of a multidisciplinary team approach with early goals of care discussion.