Acute hemorrhagic necrotizing pancreatitis is a type of acute pancreatitis, resulting from the progression of acute edematous pancreatitis. The pancreatic acini, fat, and blood vessels undergo extensive necrosis, with pancreatic tissue edema, enlargement in size, and widespread hemorrhagic necrosis. A large amount of bloody exudate accumulates in the retroperitoneal space. The mesentery and omentum are digested by the leaked pancreatic enzymes. This type of pancreatitis is severe, progresses rapidly, has numerous complications, and carries a high mortality rate.

bubble_chart Clinical Manifestations

Sudden onset of severe pain in the upper abdomen or the appearance of high fever, diffuse peritonitis, paralytic ileus, upper abdominal mass, gastrointestinal bleeding, neuropsychiatric symptoms, and shock during the treatment of acute edematous pancreatitis.

bubble_chart Auxiliary Examination

1. Hematuria. Amylase levels may remain persistently elevated or fail to rise due to extensive pancreatic necrosis. A decrease in blood calcium, with values <1.74mmol/L (7mg%), indicates a poor prognosis. Blood sugar increases, leading to glycosuria. Serum methemoglobin is positive.
2. Peritoneal puncture fluid appears bloody and turbid, with elevated amylase and lipase levels.
3. B-ultrasound examination may reveal pancreatic enlargement with sparse internal echo reflections. CT shows diffuse pancreatic enlargement, irregular contours, blurred margins, and widened peripancreatic spaces.

bubble_chart Diagnosis

1. Symptoms: Sudden onset of severe pain in the upper abdomen or during the treatment of acute edematous pancreatitis, accompanied by high fever, diffuse peritonitis, paralytic ileus, upper abdominal mass, gastrointestinal bleeding, neuropsychiatric symptoms, and shock.
2. Signs: Abdominal distension, tenderness and rebound tenderness, shifting dullness, absence of bowel sounds. A few patients may develop subcutaneous fat necrosis due to bloody exudate containing pancreatic enzymes infiltrating the subcutaneous tissue through the retroperitoneal space, presenting as ecchymosis on both sides of the abdominal wall and periumbilical discoloration.

bubble_chart Treatment Measures

1. Anti-shock, correct typical edema and electrolyte imbalance: Supplement potassium, calcium, and magnesium based on blood generation and transformation test results. Administer whole blood and plasma to restore blood volume and improve microcirculation. If necessary, use positive inotropic drugs (dopamine, dobutamine, isoproterenol).
2. NPO, total parenteral nutrition (TPN): Use a glucose/amino acid system; the non-protein calorie-to-nitrogen ratio should be approximately 150–200:1, with caloric intake of 146–188 kJ/kg (35–45 kcal/kg) and fluid volume of 30–45 ml/kg.
3. Inhibit enzyme protein synthesis in pancreatic exocrine cells: Begin intravenous infusion of 5-fluorouracil 250 mg dissolved in 500 ml of fluid immediately postoperatively for 5–7 days. Administer FOY (gabexate mesilate) 100–200 mg, 1–3 times daily for 5–7 days.
4. Anti-infection: Common pathogens include mixed aerobic and anaerobic infections, such as enterococci, large intestine bacilli, Alcaligenes faecalis, Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella spp., Bacteroides fragilis, Clostridium perfringens, etc. Use clindamycin, piperacillin, and metronidazole. Perform blood cultures and sensitivity tests if necessary.
5. Peritoneal lavage: Perform catheter insertion and peritoneal lavage, infusing 12–24 L of balanced salt solution within 24 hours to reduce toxic symptoms.
6. Surgical treatment:
   1. Indications: Unconfirmed diagnosis but with acute peritonitis; acute pancreatitis with shock or concurrent biliary stones, biliary ascariasis, acute suppurative cholangitis, obstructive jaundice, pancreatic abscess, or pancreatic pseudocyst.
   2. Timing of surgery: If abdominal pain, abdominal distension, and fullness persist despite aggressive treatment, toxic symptoms worsen, or bloody effusion is found on abdominal puncture, surgery should be performed. Earlier intervention reduces mortality.
   3. Surgical approach: In the early stage, focus on drainage and debridement of necrotic tissue; in the late stage [third stage], address pancreatic and extrapancreatic infections and complications.
      1. For critically ill patients unable to tolerate major surgery, simple peripancreatic and peritoneal drainage may be performed.
      2. If the patient's condition permits, perform debridement and drainage of pancreatic necrotic tissue.
      3. Partial or total pancreatectomy should be approached cautiously. If necessary, perform three ostomies (exploratory common bile duct fistulation, decompressive gastrostomy, and jejunal feeding fistulation).