Infected pancreatic necrosis — FFICM MCQ

Correct answer: C — Discuss step-up drainage and debridement strategy with specialist centre

The correct answer is C, discuss step-up drainage and debridement strategy with specialist centre. This patient has walled-off necrosis with gas locules (suggesting infected necrosis) and a drainable collection, plus clinical deterioration (fever, rising vasopressor needs) at 12 days, which is the classic window for intervention once necrosis has become walled-off and organised. Current UK practice, per NICE NG104, mandates a minimally invasive step-up approach (percutaneous or endoscopic drainage first, escalating to minimally invasive necrosectomy only if needed) delivered through multidisciplinary discussion with a specialist pancreatic centre rather than immediate major surgery. Early drainage before the collection is walled off, or open necrosectomy as a first step, carries substantially higher morbidity and mortality than a staged, image-guided approach. Source control combined with targeted antibiotics (guided by cultures/aspirate) is the priority once infection is suspected, not antibiotics or nutrition alone. Why the other options are wrong: A, Perform immediate open necrosectomy for the necrotic area: open necrosectomy as a first-line intervention carries high morbidity and mortality and is reserved for cases where minimally invasive step-up drainage fails or is not feasible, not as an initial default. B, Stop enteral feeding and start TPN as definitive therapy: enteral feeding should be continued or resumed wherever possible in pancreatitis to preserve gut mucosal integrity and reduce infective complications; TPN is not definitive treatment for infected necrosis and does not address the need for source control. D, Treat with prophylactic antibiotics alone: antibiotics alone cannot sterilise necrotic, poorly vascularised pancreatic tissue with gas locules; source control by drainage or debridement is required once infection is suspected, with antibiotics as an adjunct guided by cultures. E, Discharge once lipase falls: lipase level does not reflect resolution of a large infected necrotic collection with sepsis and vasopressor requirement; discharge here would be unsafe and negligent. Key point: Once walled-off pancreatic necrosis is suspected to be infected (gas locules, sepsis, rising vasopressor need), management is a staged, minimally invasive step-up drainage and debridement strategy planned with a specialist pancreatic centre, not immediate open surgery.

Reference: NICE Guideline NG104, Pancreatitis (2018, updated), Recommendations on management of complications: https://www.nice.org.uk/guidance/ng104/chapter/recommendations