Pancreatic ascites: recognition and management

Imaging Diagnosis and Management of Fistulas in Pancreatitis

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Outcome of surgery for chronic pancreatitis related pancreatic ascites and pancreatic pleural effusion

Background

An internal pancreatic fistula involves an abnormality in the way that the pancreas communicates with organs and spaces within the body. This is usually due to a disrupted pancreatic duct or psuedocyst leakage (Ascitic or pleural fluid amylase level >1000 S units/dl and fluid protein level >3 g/dl). The study aims to report our experience with surgery for chronic pancreatitis-related pancreatic ascites and pancreatic pleural effusions.

Methods

All the patients, who underwent surgical intervention for pancreatic ascites and pancreatic pleural effusion between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed.

Results

Of the total 14 patients, 10 (71.4%) were men with a median age of 40 (4–49) years. The median interval between onset of symptoms of CP and diagnosis of IPF was 27 (3–60) months. All patients had a history of chronic abdominal pain and 5 (35.7%) had a prior history of hospitalization for pain. Eleven patients (78.5%) presented with abdominal distension and 3 (21.4%) patients had respiratory distress. Six (42.8%) patients had undergone endotherapy before surgery. Contrast-enhanced computed tomography detected pancreatic pseudocyst in 10 (71.42%) patients. The most commonly performed operation was lateral pancreaticojejunostomy (n = 11, 78.5%). Seven postoperative complications developed in 4 (28.5%) patients. After a median follow-up of 60 (6–86) months, no patient developed recurrence of pancreatic ascites or pleural effusion.

Conclusion

In the experienced hand, surgery can be performed with acceptable perioperative morbidity and mortality and long-term satisfactory outcomes.

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Internal Pancreatic fistula is a rare complication of chronic pancreatitis.

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Surgery is indicated after failure of medical and endoscopic therapy.

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Surgery can be performed with acceptable perioperative morbidity and mortality and long-term good results.

Safety and Efficacy of Early Endotherapy in Management of Pancreatic Ascites: Western Indian Experience

Background Pancreatic ascites is rare but a known complication of pancreatitis. We aimed to study the timings, safety, and efficacy of therapeutic approaches in its management and the outcomes.

Methods We retrospectively studied patients with pancreatic ascites managed in the past 5 years at a single tertiary care center. Therapeutic approaches included conservative therapy, early endoscopic therapy, and surgery. We used descriptive statistics to summarize characteristics of the study population, and performed univariate and binary logistic regression analyses to compare treatment outcomes.

Results Of the 125 patients screened, 70 (male, 81.4%) were included. Disruption in the pancreatic duct (PD) was seen in 51.4% of patients on magnetic resonance cholangiopancreatography (MRCP) and 73.3% of patients on endoscopic retrograde cholangiopancreatography (ERCP). The PD in the body region (46.7%) was the most frequent site of disruption. Early endotherapy included a stent bridging the disruption site in 63.3% of patients and sphincterotomy in 76.7% of patients with a median time to ERCP from symptom onset being 8.5 days. The success rate in early endotherapy was 81.7%, while the recurrence rate was 8%. For conservative therapy only, the success rate was 60% with recurrence in two-thirds. The variables crucial in the success of endotherapy were a partial disruption (p < 0.001), ductal disruption site (p = 0.004), sphincterotomy (p = 0.013), and a bridging stent (p = 0.001). Significant pancreatic necrosis (p < 0.001) and intraductal calculi (p = 0.002) were the factors responsible for failure in endotherapy.

Conclusions Early endotherapy is safe and effective in the treatment of pancreatic ascites. The efficacy of endotherapy is augmented by PD stenting combined with pancreatic sphincterotomy and a bridging stent.

Endoscopic Retrograde Cholangiopancreatography Induced Pancreatic Ascites

Pancreatic pathology is one of the causes of abdominal ascites. The estimated prevalence of pancreatic ascites is 3.5% in patients with chronic pancreatitis and it is mostly caused by pancreatic duct dehiscence in the setting of chronic pancreatitis. Other etiologies include pancreatic pseudocysts, trauma, severe acute pancreatitis and rupture to the pancreas. Management of this condition includes conservative management like holding feeds, total parenteral nutrition, administering somatostatin analogues or sometimes invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP) and surgery. ERCP is an unusual cause of pancreatic ascites and only one other case report has linked an association between ERCP and the development of pancreatic ascites. Our case report contributes to this literature and aims to shed light on this under-reported cause of pancreatic ascites.

Ascites in acute pancreatitis: not a silent bystander

BACKGROUND & AIM

Ascites in patients with acute pancreatitis (AP) is understudied although recent literature hints at its evident role in the final outcome. This study was planned to study the characteristics of ascites in patients of AP and its effect on the disease course and outcome.

METHODS

Consecutive patients of AP were studied and patients with or without ascites were evaluated for the baseline parameters and severity assessment. Ascites was quantified and fluid analyzed for its characteristics. Intraabdominal pressure (IAP) was monitored. The various outcome parameters were compared between the two groups of patients with and without ascites.

RESULTS

Of the cohort of 213 patients, 82 (38.5%) developed ascites. Ascites group had significantly higher rates of organ failure (p = 0.001), necrosis (p=<0.001) and higher severity assessment scores. The ascites group had significantly longer hospital and ICU stay and higher ventilator days compared to the non-ascites group. Mortality was also higher in the ascites group (34.1% vs 8.45; p = 0.001). Majority of patients with ascites had moderate to gross ascites (75.6%), low serum ascites albumin gradient (87.8%) with low amylase levels (71.9%). Sub-group analysis in ascites group showed that patients with fatal outcome had higher rates of moderate to gross ascites, higher baseline IAP and lower reduction in IAP after 48 h. Moderate to gross ascites and grades of intra-abdominal hypertension (IAH) were significant predictors of mortality (AUC - 0.76).

CONCLUSION

AP patients with ascites have a more severe disease with poorer outcome. Higher degrees of ascites and IAH grades are significant predictors of mortality.

Extraperitoneal Fluid Collection due to Chronic Pancreatitis

A 39-year-old man was referred to our hospital for the investigation of abdominal fluid collection. He was pointed out to have alcoholic chronic pancreatitis. Laboratory data showed inflammation and slightly elevated serum direct bilirubin and amylase. An abdominal computed tomography demonstrated huge fluid collection, multiple pancreatic pseudocysts and pancreatic calcification. The fluid showed a high level of amylase at 4,490 IU/l. Under the diagnosis of pancreatic ascites, endoscopic pancreatic stent insertion was attempted but was unsuccessful, so surgical treatment (Frey procedure and cystojejunostomy) was performed. During the operation, a huge amount of fluid containing bile acid (amylase at 1,474 IU/l and bilirubin at 13.5 mg/dl) was found to exist in the extraperitoneal space (over the peritoneum), but no ascites was found. His postoperative course was uneventful and he shows no recurrence of the fluid. Pancreatic ascites is thought to result from the disruption of the main pancreatic duct, the rupture of a pancreatic pseudocyst, or possibly leakage from an unknown site. In our extremely rare case, the pancreatic pseudocyst penetrated into the hepatoduodenal ligament with communication to the common bile duct, and the fluid flowed into the round ligament of the liver and next into the extraperitoneal space.

Successful Management of Pancreatic Ascites with both Conservative Management and Pancreatic Duct Stenting

Pancreatic ascites is a rare complication and should be suspected in patients with chronic alcoholism and pancreatitis presenting with ascites. The etiology is likely from a pancreatic pseudocyst leakage or due to ductal disruption. Treatment is controversial but includes conservative medical therapy or endoscopic transpapillary pancreatic duct stenting or surgery. We present a case of pancreatic ascites in a patient with alcohol use and chronic pancreatitis. Patient received conservative therapy including octreotide. An endoscopic retrograde cholangiopancreatography was performed, which confirmed a pancreatic duct dehiscence with extravasation of the injected contrast. This was treated with placement of a stent. Patient improved clinically and symptomatically. This case report augments the existing data from two prior reported case series, and this modality of management should be actively pursued in such cases.

Extra-hepatic biliary-ductal necrosis following acute pancreatitis: 10 years of follow-up

This case report is 10 years follow-up of a child who presented with acute abdomen at the age of 8 years. Exploration revealed acute pancreatitis with the necrosis of common bile duct and almost whole of the common hepatic duct with bile leaking from the junctional stump of the right and left hepatic ducts. The patient was managed successfully by Roux-en-Y hepaticojejunostomy. After 10 years, the patient again presented with a recurrent discharging sinus from the anterior abdominal wall. On exploration, it was found to be a stitch granuloma near the site of hepaticojejunostomy. However, hepaticojejunostomy was found to function normally as seen on MRCP. This rare case highlights that extra-hepatic biliary-ductal necrosis is very unusual complication of acute pancreatitis; and it can be successfully managed by Roux-en-Y hepaticojejunostomy as evident from long-term follow-up.

Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis

BACKGROUND AND AIMS

Internal pancreatic fistulas (IPF) are an uncommon but well-recognized complication of chronic pancreatitis (CP) that are associated with significant morbidity and mortality. Because of their low incidence, management is still controversial. The aims of this study are to report the 8-year experience with IPF management in a Brazil University-affiliated hospital and to propose a management algorithm.

STUDY

A centralized diagnostic index was used to retrospectively identify all patients with IPF admitted to a teaching hospital from 1995 to 2003. The patient's medical records were reviewed for clinical features, diagnostic work-up, treatment strategies, response to therapy, and the length of hospital stay. All patients underwent contrast-enhanced computed tomography of the abdomen and endoscopic retrograde cholangiopancreatography, to guide the therapeutic modality to be offered. Conservative therapy included withholding of oral feedings in conjunction with total parenteral nutrition, octreotide subcutaneously, and multiple paracentesis or thoracentesis. Interventional therapy was either endoscopic or surgical.

RESULTS

IPF was identified in 11 (7.3%) of 150 patients with CP. They ranged in age from 24 to 47 years (mean 36.1), with a male to female ratio of 10:1. All patients had underlying alcoholic CP. The presentation was pancreatic ascites in 9 patients and pleural effusion in 2 cases. Five patients were undergoing the conservative treatment, all presenting main pancreatic duct (MPD) dilatation; endoscopic placement of transpapillary pancreatic duct stent was performed in 4 patients who presented partial MPD stricture or disruption; surgical therapy was performed in 2 patients exhibiting complete MPD obstruction or disruption. Stents were removed 3 to 6 weeks after initial placement. IPF resolved in 10 of 11 patients (90.9%) within 6 weeks. The resolution of IPF was faster (13 +/- 5 vs. 25 +/- 13 days, P < 0.01) and the length of hospital stay was significantly shorter (17.2 +/- 5.6 vs. 31.2 +/- 4.4 days, P < 0.01) in patients subject to interventional treatment compared with those treated conservatively. There was 1 death due to sepsis in a patient managed conservatively; no death was recorded in the interventional therapy group. There was no recurrence of IPF at a mean follow-up of 38 months.

CONCLUSIONS

Our results suggest that interventional therapy should be considered the best approach for the management of IPF in patients presenting MPD disruption or obstruction. Conservative therapy must be reserved for those showing MPD dilatation without ductal disruption or stricture. Early interventional therapy reduced hospital stay and convalescence, which likely resulted in lower healthcare overall costs.

Surgical management of pancreaticocutaneous fistula

Although enteric drainage of the fistula tract is a widely accepted treatment for pancreaticocutaneous fistula, few data have been published on the outcome of this procedure. We conducted a retrospective chart review of 30 patients with pancreaticocutaneous fistula who underwent surgical management at a single institution over a 13-year period. The operative morbidity rate was 30%. Overall the incidence of recurrent ductal leaks requiring further intervention was 23%. Six of seven patients who had a recurrence had an ongoing inflammatory pathology, and three of seven had pancreas divisum. Recurrence was most likely when cystenterostomy was used. Enteric drainage of pancreaticocutaneous fistulas is not always curative. Fistulojejunostomy gives a better outcome than cystenterostomy. Recurrence may be expected in patients with continuing inflammatory ductal pathology.

Pancreatic ascites: study of therapeutic options by analysis of case reports and case series between the years 1975 and 2000

OBJECTIVE

Because of the low incidence of pancreatic ascites, only case reports and case series have been published, and no randomized controlled trials have been performed to find out which is the best therapeutic approach. The aim of this study was to evaluate the utility of the different treatments for pancreatic ascites by a thorough review of all case reports described in the literature in which an independent analysis of the efficacy of the treatment administered to each patient is possible.

METHODS

We conducted an analysis of all case reports and case series of pancreatic ascites published between 1975 and 2000 in which clinical data of every patient could be identified individually. A total of 139 cases were studied. Clinical characteristics, treatments administered, and response to therapy of every patient were registered. Conservative therapy included drainage of ascitic fluid, total parenteral nutrition and diet, and somatostatin analogues. Interventional therapy was either endoscopic or surgical.

RESULTS

After multivariate analysis, the only treatments related to success were surgery (adjusted OR = 8.2, 95% CI = 3.0-22.9) and transpapillary stent (adjusted OR = 7.3, 95% CI = 0.8-62.9). No significant relationship was found between failure or death and the use of other treatments, age, sex, year of publication, underlying disease, site of leakage, or serum amylase levels. The apparent lack of effect of somatostatin analogues could be attributed to the small number of cases and the heterogeneity of the dosages.

CONCLUSIONS

Conservative therapy is not advisable for pancreatic ascites because of the high proportion of failures. Interventional therapy with surgery or transpapillary stent has a positive effect in the clinical outcome.

The ascites to serum amylase ratio identifies two distinct populations in acute pancreatitis with ascites

BACKGROUND/AIM

While the characteristics of ascites in the setting of chronic pancreatitis are well established, little has been written about the characteristics of spontaneous, clinically apparent ascites in the setting of acute pancreatitis. Our aim was to define the characteristics of clinically apparent ascites complicating acute pancreatitis, particularly with regard to outcomes.

METHODS

We performed a search of our hospital's discharge records for ICD codes 577.0 (acute pancreatitis) and 789.5 (ascites). Clinical and laboratory variables in survivors and nonsurvivors were compared using a Mann-Whitney U test.

RESULTS

We identified 59 records of which 25 cases had ascites fluid analysis. Only the ascites amylase (p = 0.033) and the ascites to serum amylase ratio (p = 0.002) correlated with mortality. Setting a cutoff of 1, the ascites to serum amylase ratio achieved a sensitivity of 83% and a specificity of 92% as a predictor of mortality.

CONCLUSIONS

The ascites to serum amylase ratio identifies 2 sets of patients with ascites complicating acute pancreatitis. In patients with a high ratio, ascites may result from a localized duct disruption. In patients with a low ratio ascites may be secondary to comorbid conditions or a capillary leak. In acute pancreatitis with clinically apparent ascites, the ascites to serum amylase ratio may be a predictor of mortality.

Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management

BACKGROUND

Internal pancreatic fistulas are well recognized complications of chronic pancreatitis.

METHODS

Six patients with internal pancreatic fistulas were treated over a period of 5 years from 1995 to 1999. Four patients presented with ascites, one patient presented with ascites and bilateral pleural effusion and the sixth patient presented with left-sided pleural effusion. Five patients were chronic alcoholics and in one patient the cause of pancreatitis was not clear. Although the serum amylase was mildly elevated the levels of amylase in the aspirated fluid were consistently elevated (more than 800 Somogyi units/100 mL), along with the level of proteins (> or = 3 g/100 mL), and on this basis the diagnosis was made. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated pancreatic ductal disruption in four cases. Initial treatment was conservative, consisting of nasogastric aspiration, nil per oral, antisecretory drugs, repeated paracentesis or thoracocenthesis and total parenteral nutrition (TPN). In two patients naso-pancreatic drains (NPD) were placed across the disrupted pancreatic duct.

RESULTS

In one patient conservative treatment with NPD was successful, and the remaining five patients required surgical intervention. There was no mortality. Two patients developed surgery-related complications that were successfully managed, but they required an extended hospital stay.

CONCLUSION

Internal pancreatic fistulas should be treated initially non-operatively; if this is not effective, operative therapy should be considered without delay.

Endoscopic pancreatic duct stenting to treat pancreatic ascites

BACKGROUND

Management of pancreatic ascites with conservative medical therapy or surgery has met with limited success. Decompression of the pancreatic ductal system through transpapillary stent placement, an alternative strategy, has been reported in only a handful of cases of pancreatic ascites.

METHODS

We reviewed all cases from 1994 to 1997 in which patients with pancreatic ascites underwent an endoscopic retrograde pancreatogram documenting pancreatic duct disruption with subsequent placement of a transpapillary pancreatic duct stent. Clinical end points were resolution of ascites and need for surgery.

RESULTS

There were 8 cases of pancreatic ascites in which a 5F or 7F transpapillary pancreatic duct stent was placed as the initial drainage procedure. Pancreatic ascites resolved in 7 of 8 patients (88%) within 6 weeks. Ascites resolved in the eighth patient, a poor candidate for surgery, following placement of a 5 mm expandable metallic pancreatic stent. No infections, alterations in ductal morphology, or other complications related to stent placement were noted. There was no recurrence of pancreatic ascites or duct disruption at a mean follow-up of 14 months.

CONCLUSIONS

Our experience doubles the number of reported cases in which transpapillary pancreatic stent placement safely obviated the need for surgical intervention in the setting of pancreatic ascites. This therapeutic endoscopic intervention should be seriously considered in the initial management of patients with pancreatic ascites.

A study of forty-nine consecutive Whipple resections for periampullary adenocarcinoma

BACKGROUND

We designed a program to evaluate the morbidity, mortality, survival rates, and patient's quality of life after Whipple resection for pancreatic and other periampullary adneocarcinoma.

PATIENTS AND METHODS

After studying 11 fresh and unembalmed cadavers to learn the regional anatomy and to practice the surgical techniques for traditional Whipple procedure by the senior author (JS), 49 patients aged 56 to 84 years old were treated with Whipple's pancreatoduocenectomy.

RESULTS

There was no postoperative mortality or morbidity from anastomotic leakage. All 49 patients were discharged in an improved condition following surgery, including 5 patients with emergency resection. Eight patients are alive at the time of this writing, including 2 patients who had their pancreatic cancer resected 168 and 139 months ago.

CONCLUSIONS

In the opinion of these authors, treatment of all resectable cancers with Whipple's pancreatoduodenectomy offers not only a superior palliation but also the hope of cure.

Resolution of refractory pancreatic ascites after continuous infusion of octreotide acetate

The treatment of pancreatic ascites remains a clinical challenge. Both medical and surgical management have high rates of mortality and recurrence. New methods in the treatment of pancreatic ascites are actively sought. We describe the successful use of a continuous infusion of octreotide acetate in the treatment of refractory alcoholic pancreatic ascites.

Endoscopic treatment of pancreatic ascites

Pancreatic ascites, etiologically related to a leaking pseudocyst or ductal disruption, has been treated medically with hyperalimentation, somatostatin analog, and large-volume paracentesis. Surgery is ultimately required in more than 50% of such patients. Mortality figures in patients with pancreatic ascites approximate 15% to 25% with either treatment modality. We describe 4 patients who were found to have ductal disruptions in conjunction with pancreatic ascites who responded to transpapillary pancreatic duct endoprosthesis placement. There has been no recurrence of ascites in these patients at a mean follow-up of 12 months following stent-retrieval. Further evaluation of endoscopic therapy for pancreatic ascites appears warranted.

Endoscopic stent placement for internal and external pancreatic fistulas

Stents have been effectively used for various pancreatic conditions. Pancreatic fistulas, however, have traditionally been considered a surgical disease, and if the fistula does not respond to conservative measures, an operation is usually performed. Stents were placed endoscopically in five consecutive patients who presented with pancreatic fistulas that did not respond to conservative management. Fistulas resolved in all patients after endoscopic stent placement, and after 14-30 months of follow-up, none has recurred. The cases comprise two patients with pancreaticocutaneous fistula and one each with pancreaticopleural, pancreaticoperitoneal, and pancreaticocholedochal fistula. The need for an operation can be obviated in many patients with internal and external pancreatic fistulas.

Internal pancreatic fistula

Internal pancreatic fistulae are well-recognized complications of inflammatory pancreatic disease. From 1963 to 1990, 50 patients with either pancreatic ascites (34), pancreatic ascites and pleural effusion (7), or pancreatic pleural effusion (9) were treated. Initial therapy was conservative, consisting of gastrointestinal rest, serosal apposition with paracentesis or thoracentesis, with or without the administration of anti-secretagogues. This therapy was successful in 21 of 42 patients, but 5 deaths occurred. Operative therapy was performed in 24 patients. There was one surgical failure and two deaths early in the experience. Ten of our final 16 patients underwent liver biopsy, and all 10 were found to have cirrhosis. All patients, even those with documented cirrhosis, should have routine amylase and albumin determinations on ascitic or pleural fluid. Internal pancreatic fistulae should be treated initially nonoperatively; if this is ineffective, operative therapy has an acceptably low morbidity and mortality.

Radiologic evaluation of pancreatic ascites

Two cases of pancreatic ascites are presented in which preoperative endoscopic retrograde pancreatography (ERP) precisely identified the exact location of the leakage of pancreatic juice into the peritoneal cavity. Computed tomography was not helpful in either case. Endoscopic retrograde pancreatography is the most valuable imaging examination to confirm the diagnosis of pancreatic ascites and to direct surgical management.

Surgical treatment of chronic pancreatitis: an overview

The correct management of chronic pancreatitis remains undecided. The aims of surgical treatment are to relieve pain, treat complications and preserve pancreatic function. The appropriate surgical procedure to achieve these ends must be carefully chosen.

Peritoneovenous shunt for pancreatic ascites

A chronically ill patient with pancreatic ascites was successfully treated with a temporary LeVeen peritoneovenous shunt. This observation supports the use of a peritoneovenous shunt in the treatment of pancreatic ascites which is refractory to medical therapy and not amenable to major pancreatic surgery.

Acute pancreatitis and its complications. Diagnostic and therapeutic strategies

The most common causes of acute pancreatitis are biliary tract disease and alcoholism, but other causes account for about 10% of cases. Acute pancreatitis can be divided clinically into mild and severe (necrotic) disease. Risk of complications and death varies with the etiology, severity, and number of episodes and is highest in severe cases and biliary tract-related disease. Amylase determination is the best diagnostic serum screening test. Ultrasonography, computed tomography, and endoscopic retrograde pancreatography are also extremely useful in diagnosis. Treatment of acute pancreatitis usually consists of supportive measures; the roles of peritoneal lavage and surgery remain controversial. Pseudocysts occur in about 25% of patients but can be treated successfully with appropriate therapy.

Conservative management of pancreatic ascites

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The value of operative pancreatography

Between 1978 and 1982 operative pancreatography was undertaken in 39 patients (mean age 47 years) using 1 of 4 different techniques. Final diagnoses were chronic pancreatitis (15), isolated dorsal pancreas (10), carcinoma head of pancreas (3), acute pancreatitis (3) and miscellaneous pancreatic conditions (8). Retrograde (transduodenal) pancreatograms were successfully obtained in 10 of 12 patients, including 3 via the minor papilla. Prograde cannulation was achieved after distal pancreatectomy in 15 of 16 patients, 10 of whom had an isolated dorsal pancreas. 'Ambigrade' pancreatography was performed after direct puncture of a palpable duct in 6 patients and cystography in another 5 patients with pseudocysts. No complications of pancreatography were seen and the radiological findings modified the operative procedure in 16 patients (41 per cent).

Recurrence of pancreatic ascites due to a second leak demonstrated radiologically

A case of recurrent pancreatic ascites is reported in which both episodes were investigated by endoscopic retrograde pancreatography.

Massive pancreatic serous effusions

The condition of massive pancreatic serous effusion is being increasingly recognized as a specific complication of pancreatitis. It occurs as a result of leakage of pancreatic juice into the pleural or peritoneal cavity after disruption of the duct system. Five such cases are described. The difficulties in making the diagnosis are mainly due to the absence of symptoms of pancreatitis, and most patients present because of the effects of the effusion. Once suspected, the diagnosis is confirmed by the demonstration of a grossly elevated amylase level in the fluid. A rational surgical approach is usually successful, and depends on the demonstration of a leak from a pseudocyst or disruption of the pancreatic duct system.

Improved management of pancreatic lesions in children aided by ERCP

Internal pancreatic fistulas have only recently been recognized as distinct entities in children. Unless their pathophysiology is understood they can present the clinician with a diagnostic dilemma. Recently, these entities have been better defined in the adult literature and significant improvement made in treatment. We report a case of a child with pancreatic ascites in whom endoscopic retrograde cholangiopancreatography significantly aided the diagnosis and the operative management. An outline of recommended management of pancreatic lesions in children is presented including internal pancreatic fistulas.

Pancreatic ascites: a rare complication of distal splenorenal shunt

Ascites has become recognized as a common postoperative complication of the distal splenorenal shunt. On rare occasions the ascites has been chylous in nature. The present report is the first documented case of pancreatic ascites occurring after this operation. This complication developed in the combined setting of chronic pancreatitis and surgical trauma to the pancreas. Since the management of pancreatic ascites differs from that of cirrhotic or chylous ascites, it is recommended that this diagnosis be considered whenever a patient develops severe ascites after a distal spenorenal shunt.

Pancreatic ascites and pleural effusions

Two cases of pancreatic ascites are presented and reviewed, together with 92 cases of internal pancreatic fistula reported in the recent literature. Alcohol abuse is the predominant aetiological factor, and chronic pancreatitis with an associated pseudocyst the most common pathological finding. The diagnosis depends on clinical suspicion and can be confirmed by the estimation of amylase and protein levels in the aspirated fluid. Medical treatment includes the aspiration of fluid accumulations, inhibition of pancreatic secretion, and nutritional augmentation. The use of pancreatography is recommended as a guide to the appropriate surgical procedure in patients who do not respond to medical therapy. Overall results indicate a cure rate of 77% and a mortality of 19%.