Episode three picks up where the pancreas has declared itself necrotic and organizes the collection nomenclature on timing and content. Necrosis is managed by delay, drain, then debride, with endoscopic transmural drainage now favored because it never crosses the peritoneum. The vascular complications split by vessel: venous thrombosis usually self-resolves, while a pseudoaneurysm mandates CT angiography and embolization before any drainage. The post-ERCP triad attacks three independent nodes, and recurrent disease is worked up by escalation from baseline labs to MRCP to endoscopic ultrasound for microlithiasis, with the pancreas divisum trap waiting at the end. Topics covered Recognizing necrosis and infected necrosis Collection nomenclature by timing and content Step-up management: delay, drain, debride Endoscopic versus surgical step-up Splanchnic venous thrombosis and left-sided portal hypertension Arterial pseudoaneurysm and pre-drainage angiography Post-ERCP pancreatitis and its prevention triad Recurrent and idiopathic disease workup Pancreas divisum and prevention by stopping the cause Key decisions Diagnose necrosis by non-enhancing parenchyma on contrast CT and read gas in a peripancreatic collection, absent recent intervention, as essentially diagnostic of infected necrosis. Name collections by timing and content: acute peripancreatic fluid collection and pseudocyst without necrosis, acute necrotic collection and walled-off necrosis with necrosis, split at four weeks. Follow the step-up principle of delay past four weeks, drain percutaneously or endoscopically first, and debride only when drainage fails or solid debris obstructs it, favoring endoscopic transmural drainage with a lumen-apposing metal stent. Withhold anticoagulation for isolated splenic vein thrombosis, reserving it for clot extending into the portal or superior mesenteric vein, and treat bleeding gastric varices from left-sided portal hypertension with splenectomy. Image the arterial anatomy before any necrosectomy or cyst drainage and embolize a pseudoaneurysm first, because manipulation risks catastrophic hemorrhage. Prevent post-ERCP pancreatitis in high-risk cases with all three pillars: rectal indomethacin one hundred milligrams, a prophylactic pancreatic duct stent, and peri-procedural lactated Ringer's. Work up recurrent disease by escalation from baseline labs to MRCP to endoscopic ultrasound for microlithiasis and tumors, add genetic testing under thirty-five, and offer cholecystectomy after a second idiopathic episode. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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