Strictures, leaks, ascites: An unusual case of necrotizing pancreatitis

Document Type

Conference Proceeding

Publication Date

10-1-2021

Publication Title

Am J Gastroenterol

Abstract

Introduction: Chronic pancreatitis complications consists of pseudocysts, strictures, and necrosis. There is less than 10% incidence of pancreatic ascites reported as a complication. It is usually caused pancreatic pseudocyst leak or pancreatic duct (PD) disruption. We describe an unusual case of necrotizing pancreatitis complicated by ascites and pancreatic duct stricture. Case Description/Methods: A 43 year old man with medical history of recurrent pancreatitis with ascites who presented with epigastric pain that wakes him up from sleep for 5 days. Vitals were stable. Exam revealed positive fluid wave shift and diffuse tenderness. Labs were significant for lipase 1,318 IU/L. MRI pancreas showed moderate volume ascites, pancreatic edema and prominent surrounding peripancreatic fluid, consistent with ongoing pancreatitis. A portion of the pancreatic body did not show evidence of enhancement, a finding of pancreatic necrosis, measuring about 25-33% of the total gland volume. It showed a cystic structure associated with the pancreatic uncinated process measuring 2.1 x 2.7 x 5.0 cm. There was also peritoneal enhancement present, suggestive of peritonitis. Paracentesis took off 4.4 L. Ascitic fluid analysis showed lipase 43,794 U/L and amylase 18,920 IU/L consistent with pancreatic ascites and concerning for PD leak. ERCP did not demonstrate leak but a concern for PD stricture with potential for future leak. A 7 French by 9 cm pancreatic stent was placed into the ventral PD but it was too short to traverse the stricture; stent was removed and replaced with a 7 French by 12 cm stent. Four week follow up for stent retrieval was performed, only to find the patient now had a PD leak. Therefore, stent was replaced. Patient was advised to follow up in 4 weeks for stent removal. Discussion: This was a rare case of necrotizing pancreatitis complicated by pancreatic ascites. Management of pancreatitis is usually conservative, but interventional treatment should be performed for symptomatic patients. The focal stricture with upstream dilation in the pancreatic body was suspected to be secondary to chronic pancreatitis. Due to the finding of a stricture and likely developing necrosis on imaging, endoscopic transpapillary PD stenting was performed. The PD leak may have been missed on prior imaging, but endotherapy was required for this case. Subsequent patient follow up demonstrated resolution of ascites and pancreatitis..

PubMed ID

Not assigned.

Volume

116

Issue

SUPPL

First Page

S1429

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