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Infected Pancreatic Necrosis Step-Up — RACP Adult Medicine MCQ

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ModerateGeneral Internal MedicineInfected Pancreatic Necrosis Step-UpRACP Adult Medicine

A 40-year-old man with no past medical history develops acute pancreatitis. CT at day 5 shows 60% pancreatic necrosis. He is managed in ICU. On day 21, he develops spiking fevers with WCC 22 × 10⁹/L. CT shows a walled-off necrotic collection with gas bubbles. What is the recommended step-up approach to management?

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Correct answer: E — Repeat CT in 1 week

Infected pancreatic necrosis (gas bubbles in a walled-off necrotic collection) requires intervention. The step-up approach (PANTER trial, TENSION trial) is now the standard of care: (1) Start with IV antibiotics; (2) If not improving within 72 hours, percutaneous catheter drainage; (3) If drainage fails, minimally invasive endoscopic transgastric necrosectomy (preferred) or video-assisted retroperitoneal debridement (VARD); (4) Open surgical necrosectomy only as a last resort. This sequential approach reduces morbidity and mortality compared to direct surgical necrosectomy.

Reference: eTG – 2025 – Gastrointestinal; IAP/APA – 2024 – Acute Pancreatitis Guidelines