Clinical features and natural history of central cavitary necrosis

Central cavitary necrosis (CCN) is an unusual complication of acute pancreatitis in which the necrosis is confined almost entirely to the pancreatic parenchyma and there is little if any extrapancreatic necrosis. In our experience with 10 patients with CCN, clinical features suggested that the episodes of acute pancreatitis were initially severe, with high Ranson scores (mean, 4.2; range, 1-6), development of systemic complications, computed tomography (CT) grade of D or E by the Balthazar-Ranson scoring system, need for intensive care unit admission in 8 of 10 patients, and mean length of hospitalization of 56 days (range, 28-153 days). However, the incidence of infection was low (20%) and mortality was also low (10%). Factors that help explain a favorable prognosis were low APACHE-II scores at admission and at 48 h, absence of shock, paucity of extrapancreatic necrosis, and rapid resolution of clinical toxicity prior to the diagnosis of CCN by CT scan at a mean of 19.8 days (range, 9-63 days) after the onset of symptoms. Surgical debridement is indicated for complications such as secondary infection and ongoing pain. In the absence of complications, an attempt should be made to treat CCN medically.