Necrotizing Pancreatitis With Concurrent Clostridioides difficile Infection.

Necrotizing pancreatitis is a severe complication of acute pancreatitis that may not become radiographically evident until several days after symptom onset. Although progression from gallstone pancreatitis is well recognized, concurrent postoperative complications and Clostridioides difficile infection can obscure the clinical picture and delay diagnosis. This case adds to the literature by demonstrating how overlapping postoperative findings and concurrent infection masked the evolution of necrotizing pancreatitis despite initial clinical improvement and illustrating treatment approaches in such situations. A 61-year-old man presented with worsening right upper quadrant abdominal pain radiating to the back and was diagnosed with gallstone pancreatitis secondary to choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction followed by delayed laparoscopic cholecystectomy. After initial improvement and discharge, he returned with severe abdominal pain, nausea, vomiting, and systemic inflammatory findings. Exploratory laparotomy revealed chemical peritonitis of pancreatic origin without biliary leak or enteric perforation. During hospitalization, he developed Clostridioides difficile colitis, further complicating interpretation of persistent abdominal pain, leukocytosis, and inflammatory markers. Interval MRI ultimately demonstrated sterile peripancreatic necrosis and fluid collections consistent with necrotizing pancreatitis. The patient was managed with bowel rest, total parenteral nutrition, drainage of peripancreatic fluid, treatment of Clostridioides difficile infection, serial imaging, and multidisciplinary care involving surgery, gastroenterology, infectious disease, critical care, and internal medicine. His symptoms gradually improved, and he was discharged with outpatient surgical follow-up. This case highlights the unpredictable progression of gallstone pancreatitis to necrotizing pancreatitis despite early intervention and apparent clinical recovery. Persistent or worsening postoperative abdominal pain should prompt continued reassessment, as concurrent infections such as Clostridioides difficile may obscure an evolving pancreatic process. Serial laboratory evaluation, interval imaging, and multidisciplinary collaboration are essential for timely diagnosis and improved patient outcomes in complex cases.