Massive emphysematous pancreatitis associated with duodenal microperforation

Emphysematous pancreatitis (EP) is a rare variant of necrotizing pancreatitis which may result from bacterial superinfection of pancreatic tissue with gas-forming organisms such as Escherichia coli and Klebsiella pneumoniae. Gas formation is a consequence of mixed acid fermentation by these species, which may colonize the inflamed pancreatic tissue by intestinal translocation, hematogenous spread or direct seeding by penetrating ulcer. Previously described cases of EP associated with penetrating ulcer are exceedingly rare and typified by focal emphysema confined to the site of fistulation, often the head of pancreas. We present a case of massive emphysematous pancreatitis with pseudoaneurysm involvement and associated duodenal microperforation. Furthermore, we describe the successful operative management of this patient, who remains well in the community.