Synopsis
Name pancreatic and peripancreatic collections correctly, distinguish sterile from infected necrosis, identify bleeding or obstructive emergencies and use delayed multidisciplinary step-up treatment when safe.
- Use revised Atlanta terminology: acute peripancreatic fluid collection and pseudocyst contain fluid without necrotic debris; acute necrotic collection and walled-off necrosis contain variable solid necrosis.
- Collections younger than about four weeks usually lack a mature capsule; after maturation, a pseudocyst follows interstitial disease and walled-off necrosis follows necrotising pancreatitis.
- Do not call every post-pancreatitis collection a pseudocyst, because solid debris changes drainage technique, stent choice, infection risk and the possible need for necrosectomy.
- Stable sterile necrosis does not require prophylactic antimicrobials or automatic intervention; management includes nutrition, analgesia, organ support and purposeful follow-up imaging.
- Suspect infected necrosis with gas in the collection, positive culture, new sepsis or deterioration after initial improvement, while also searching for line, lung, urine and biliary sources.
- NICE recommends an endoscopic approach for infected or suspected infected necrosis when anatomically possible; drainage-first step-up care and delayed debridement need an expert pancreatic MDT.
- Pseudocyst intervention depends on symptoms and complications such as infection, gastric or biliary obstruction, bleeding, rupture or troublesome enlargement, not on diameter alone.
- Sudden pain, haemodynamic collapse or falling haemoglobin can indicate pseudoaneurysm bleeding into a collection; activate major-haemorrhage care and urgent CT angiography or interventional radiology.
Key red flags
New fever, rising support, bacteraemia, gas within necrotic material or decline after initial recovery raises infection and needs urgent pancreatic-MDT management.
Abrupt severe pain, gastrointestinal bleeding, bruising, hypotension or an otherwise unexplained haemoglobin drop is a vascular emergency until excluded.
Investigation priorities
Define necrosis, collection content, gas, wall maturity, extension, mass effect, vessels and procedural access routes.
Management branches
The patient is improving without sepsis, bleeding, obstruction, uncontrolled pain or nutritional compromise.
- Use accurate Atlanta terminology, record collection age and content, and establish whether the pancreatic duct or surrounding vessels are involved.
- Continue oral or enteral nutrition, analgesia, rehabilitation and cause-directed pancreatitis care without prophylactic antibiotics.
- Repeat imaging only at a clinically meaningful interval or for new symptoms, not simply to document every small dimensional change.
- Provide written warning signs and a named pancreatic follow-up route, because infection or obstruction can develop after discharge.