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Post-pancreatitis omental fat necrosis: A diagnostic dilemma
Necrosis grasa pancreática: un dilema diagnóstico
Claudia-Gabriela Moldovanua,b, Bianca Petresca,b, Andrada Ramona Trifc, George Dindelegand, Andrei Lebovicia,e,
Corresponding author
andrei1079@yahoo.com

Corresponding author.
a Department of Radiology, Emergency Clinical County Hospital Cluj-Napoca, Cluj-Napoca, Romania
b Department of Radiology, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Târgu Mureș, Romania
c Department of Pathology, Emergency Clinical County Hospital Cluj-Napoca, Cluj-Napoca, Romania
d Department of General Surgery, First Surgical Clinic, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
e Department of Radiology, University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj-Napoca, Cluj-Napoca, Romania
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A&#8211;C&#58;</span> Axial plane CECT&#58; well-encapsulated&#44; heterogeneous mass with areas of non-liquid &#40;fat&#41; densities developed in the greater omentum&#44; adherent to the anterior gastric wall &#40;white arrowhead&#41; and with some smaller arterial branches within &#40;blue arrow&#41;&#59; a small pseudocyst was seen in the pancreatic head &#40;orange arrowhead&#41; associated with subtle increase in perilesional fat attenuation&#59; the rest of the pancreatic parenchyma has a normal enhancement&#44; with no obvious glandular pancreatic necrosis&#59; increase in fat attenuation was extending to the mesenteric root&#44; right subhepatic space and right anterior pararenal compartment&#59; the mass was accompanied by the presence of multiple&#44; small nodules localized on the lateral sites of it &#40;white rings&#41;&#46; <span class="elsevierStyleBold">D&#58;</span> Intraoperative findings&#58; large amount of necrotic material adherent to the abdominal wall&#46; <span class="elsevierStyleBold">E and F&#58;</span> Histopathological findings&#58; necrotic fat areas&#44; a large numbers of shadowy outlines of fat cells accompanied by severe fibrosis&#44; inflammatory reaction&#44; foamy macrophages and small vessels&#59; a small focus of saponification &#40;black arrow&#41; was seen surrounded by inflammatory reaction&#44; fibrosis and some fat cells&#46; H&#38;E&#46; Bar<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>&#956;m&#46;</p>"
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nausea&#44; fever&#44; chills and weight loss&#46; The patient declared that the pain started two months ago&#44; after an episode of alcohol abuse&#44; which became more intense&#44; sharp and unremitting in the last three days before presentation&#46; Pain has not been relieved by any analgesics or antispasmodic medications&#46; Also&#44; he complained of episodic nausea and vomiting&#44; but denied hematemesis or diarrhoea&#46; The patient had unintentionally lost 10<span class="elsevierStyleHsp" style=""></span>kg in the last 2 weeks&#46; Upon physical examination&#44; he was febrile&#44; with a temperature of 38&#46;1<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; had severe epigastric sensitivity and abdominal rigidity&#46; Blood examination showed findings of inflammation &#40;white blood cell count&#44; 20&#44;240&#47;&#956;L with 87&#46;5&#37; neutrophils&#59; C &#8211; reactive protein &#40;CRP&#41;&#44; 13&#46;48<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; hypoproteinemia &#40;7&#46;18<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; hypopotassemia &#40;4&#46;24<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#41;&#44; hypocalcaemia &#40;6&#46;94<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; respiratory alkalosis and metabolic acidosis&#46; Liver tests were normal&#46; Serum amylase and lipase levels were increased&#58; 752<span class="elsevierStyleHsp" style=""></span>IU&#47;L &#40;normal ref&#58; 20&#8211;160&#41; and 1026<span class="elsevierStyleHsp" style=""></span>IU&#47;L &#40;normal ref&#58; 8&#8211;78&#41;&#44; respectively&#46; Previous medical history included cholecystectomy and an open surgery for incarcerated umbilical hernia&#46; His medical family history was unremarkable&#46; CECT &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#8211;C&#41; revealed a 10<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>cm well-encapsulated&#44; heterogeneous mass with areas of non-liquid &#40;fat&#41; densities located in the greater omentum&#46; It was adherent to the anterior gastric wall and to the transverse colon&#44; with mass effect on the latter&#46; There was no evidence of calcifications within&#46; The mass appeared to encase the mesenteric vessels and it was accompanied by the presence of multiple&#44; smaller nodules localized at the level of greater omentum and anterior right lateroconal&#46; The pancreatic parenchyma had a normal enhancement&#44; without obvious glandular pancreatic necrosis&#44; with the exception of the pancreatic head where a small pseudocyst &#40;2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#41; was observed&#46; Also&#44; a subtle increase in peripancreatic fat attenuation was found&#44; that extended to the mesenteric root and right anterior pararenal compartment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Because of lack of documented history of pancreatitis and imaging studies for comparison&#44; a neoplastic aetiology was considered and open surgery was performed due to the concern for peritoneal liposarcoma&#46; During surgery a large amount of necrotic material was found adherent to the abdominal wall&#44; gastric wall and transverse mesocolon &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41; and it was debrided&#46; Multiple white&#44; friable peritoneal small nodules that resembled with caseum were found&#59; therefore surgeons raised suspicion of peritoneal tuberculosis&#46; Due to the inflammatory changes developed between the transvers mesocolon and bowel loops&#44; surgeons could not explore the entire peritoneal cavity&#46; Adhesiolysis along with omentectomy were performed and samples were sent for microbiological examination&#46; Ziehl-Neelsen staining and culture were both negative for B-Koch&#46; The histological examination of the excised omentum revealed foci of shadowy outlines of fat cells with calcium deposits and foam cells &#40;foamy macrophages&#41; surrounded by inflammatory reactions and severe fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E and F&#41;&#59; no malignant cells were found&#46; We finally diagnosed this mass as extensive omental fat necrosis that occurred after an episode of alcohol-induced pancreatitis in the recent past&#46; Unfortunately&#44; after the surgery&#44; patient&#39;s condition worsened&#44; developed severe septic shock with metabolic acidosis&#44; anuric renal failure&#44; disseminated intravascular coagulation&#44; and on day 3 postoperatively&#44; the patient died&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">RAC divided acute pancreatitis &#40;AP&#41; into two morphological types based on imaging appearance on CECT&#58; acute interstitial pancreatitis &#40;AIP&#41; and acute necrotizing pancreatitis &#40;ANP&#41;&#46; ANP is subdivided into three forms&#58; pancreatic parenchymal necrosis&#44; extrapancreatic necrosis &#40;EXPN&#41;&#44; and combined necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The diagnosis of EXPN was based on CECT criteria and was later confirmed intraoperatively &#40;showing absence of pancreatic parenchymal necrosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The pathophysiological mechanism suggested being responsible for EXPN is necrosis of peripancreatic fatty tissue &#40;fat saponification&#41; caused by pancreatic enzymes&#46; Damaged pancreas releases lipolytic enzymes&#44; which autodigest peripancreatic fat tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Macrophages and other inflammatory mediators are activated within the affected adipose tissue&#44; leading to exacerbation of the inflammatory response&#46; Triglycerides are released based on response of attack of phospholipases and proteases on fatty cell plasma membranes&#46; Then the triglycerides are hydrolyzed and producing free fatty acids&#44; which then avidly chelate the salts and precipitate to produce detergents &#40;calcium depositions<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>soapy deposits in the tissues&#41;&#46; This process causes reduction of total serum calcium that often occurs in cases of severe pancreatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> After resolution of the acute exudate and ascites after an episode of pancreatitis&#44; scattered nodules of fat necrosis may be seen on CECT throughout the retroperitoneum and abdominal cavity&#44; which may seem like a &#8220;cluster of grapes&#8221; in &#8220;limited&#8221; forms&#44; mimicking peritoneal carcinomatosis or like a heterogeneous mass in &#8220;extensive&#8221; forms&#44; mimicking some peritoneal masses&#46; These nodules may cause mass effect on the adjacent structures and exhibit delayed contrast enhancement&#44; possibly as a result of the slow diffusion of contrast material through small capillaries in granulation tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Macroscopically&#44; in&#8221;limited&#8220;forms&#44; they appear like multiple white&#44; friable peritoneal small nodules due to calcium deposition &#40;saponification of fat&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;5</span></a> RAC refers to EXPN as &#8220;heterogenous collections with areas of fat surrounded by fluid density and areas with a slightly greater attenuation than seen in collections without necrosis&#46;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Koutroumpakis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> have defined EXPN based on CECT findings as &#8220;nonliquefied&#44; ill-defined&#44; nodular areas of increased peripancreatic fat attenuation&#44; with visual density higher than simple fluid or stranding&#44; or as peripancreatic necrotic fluid collection in the absence of pancreatic necrosis&#8221;&#46; The most common sites of EXPN are the lesser sac and the left anterior pararenal space&#46; The larger collections can extend retroperitoneally over the psoas muscles to enter the pelvis&#44; posterior pararenal space&#44; perirenal space&#44; transverse mesocolon&#44; and small bowel mesentery&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">EXPN may cause diagnostic dilemma and should be considered as differential diagnosis in appropriate clinical setting&#46; CT findings of these lesions can be challenging to radiologists in lack of clinical data or previous imaging series for comparison&#46; An awareness of the CECT features and evolutional appearance in these lesions may help to ensure a correct diagnosis and to avoid a misdiagnosis&#46; That it is very essential because acute pancreatitis has a potentially severe to fatal outcome and extensive EXPN was frequently associated with organ failure and a prolonged clinical course&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">A&#8211;C&#58;</span> Axial plane CECT&#58; well-encapsulated&#44; heterogeneous mass with areas of non-liquid &#40;fat&#41; densities developed in the greater omentum&#44; adherent to the anterior gastric wall &#40;white arrowhead&#41; and with some smaller arterial branches within &#40;blue arrow&#41;&#59; a small pseudocyst was seen in the pancreatic head &#40;orange arrowhead&#41; associated with subtle increase in perilesional fat attenuation&#59; the rest of the pancreatic parenchyma has a normal enhancement&#44; with no obvious glandular pancreatic necrosis&#59; increase in fat attenuation was extending to the mesenteric root&#44; right subhepatic space and right anterior pararenal compartment&#59; the mass was accompanied by the presence of multiple&#44; small nodules localized on the lateral sites of it &#40;white rings&#41;&#46; <span class="elsevierStyleBold">D&#58;</span> Intraoperative findings&#58; large amount of necrotic material adherent to the abdominal wall&#46; <span class="elsevierStyleBold">E and F&#58;</span> Histopathological findings&#58; necrotic fat areas&#44; a large numbers of shadowy outlines of fat cells accompanied by severe fibrosis&#44; inflammatory reaction&#44; foamy macrophages and small vessels&#59; a small focus of saponification &#40;black arrow&#41; was seen surrounded by inflammatory reaction&#44; fibrosis and some fat cells&#46; H&#38;E&#46; Bar<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>&#956;m&#46;</p>"
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