Colonic complications of acute pancreatitis and pancreatic abscess

Colonic involvement should be suspected in patients with severe acute pancreatitis, especially in the following clinical settings: plain abdominal radiographs suggesting bowel ischemia, colonic obstruction, acute lower gastrointestinal hemorrhage, gram-negative septicemia, enteric bacteria on Gram stain or culture of peritoneal fluid, and feculent abdominal drainage from a previously drained pancreatic abscess. Intraoperatively, the pancreas should be widely drained and the fecal stream diverted. Colonic hemorrhage and nonviable bowel require immediate resection. Broad-spectrum antibiotic administration and vigorous nutritional support also are required in these critically ill patients. Although proximal diversion and pancreatic diversion alone may suffice, colonic resection may be required later for persistent obstruction or fistulization, but in a more elective setting. Colonic anastomoses should be performed only when pancreatic inflammation and associated sepsis have resolved completely.