Antibiotic therapy has high throughput screening been established by Carbamipem and antifungal drugs administration. Course was favourable but during resolution hyperpirexia occurred, Computed tomography (CT) was performed and showed pericolic necrotic area. Therefore, we proceeded to percutaneous 12 F tubular drainage, resulting in evacuation of purulent material. We created a peritoneal cutaneous fistula, and were ready to do a so-called fistuloscopy, through abdominal wall. A bigger drainage has been replaced with 18 F drainage obtaining a hole large enough to perform endoscopy. It was carried out by 5 mm instrument, allowing selective flush out several necrotic debris, and exploration of wide cavities. Full cleaning of cavities has been obtained by four procedures. MN, 37 years old male patient complained epigastric abdominal pain radiating on the back.

After previous admittance on another hospital, he was transferred to our ward after three days. CT scan showed pancreatic oedema, and its necrotic evolution. A central venous catheter (CVC) has been placed and a feeding tube was placed over Treitz ligament by endoscopy to perform enteral nutrition (EN). EN administration (Nutricomp B, Braun, 30 ml/Kg) was associated with inflammatory markers normalization: C-reactive protein (CRP) and procalcitonin (PCT). CT scan monitoring has been performed every 7 days or in emergency if infection has been suspected; controls showed how the whole area of the gland was replaced by necrosis (Fig. 1). Patient has been discharged on 45th day and scheduled CT control scans every 2 months. Fig.

1 CT scan shows a wide necrotic area substituting whole pancreatic glande. Control CT scan showed progressive reduction on size of huge necrotic area (Fig. 2). Fig. 2 CT scan performed after 6 months and after endoscopic drainage of main pancreatic duct. BV, 30 years old male, 2 previous huge alcohol ingestion, and consequent acute pancreatitis with clouded sensorium. A new wide ingestion of spirit with emergency admission due to abdominal pain and dosage of lipases and amylase very high. Esofagogastroduodenoscopy (EGDS) performed on emergency showed duodenal loop edematous, extremely and diffuse mucosal inflammation and allowed positioning enteral nutritional tube over Treitz. CT scan showed how diffused edema has replaced whole pancreatic gland and infiltrated in retroperitoneal space.

Clinically, we observed decrease of diuresis and increase of intra-abdominal pressure (IAP), reaching on following days up to 25 H2O cm. Anyway, hemodynamic conditions were normal, with small Carfilzomib support of vasoctive amines, and fever persisted, whilst PCT was at normal level, CRP increased up to 345 U/L. In this scenario CT scan performed did not show pancreatic infection signs, and further PCT maintained between 0.4 to 0.8 U/L, whilst CRP reached 400 U/L.