Pancreatic ascites: a rare complication of necrotizing pancreatitis. A case report and review of the literature

Endoscopic management of pancreatic ascites due to duct disruption following acute necrotizing pancreatitis

Background and Aim

Acute necrotizing pancreatitis (ANP) can be associated with pancreatic duct (PD) disruption. PD disruption can lead to the formation of internal fistulae and consequent pancreatic ascites. Pancreatic ascites is reported very rarely following ANP, and therefore, the role of endotherapy in this setting is not defined. To retrospectively study the safety and efficacy of endoscopic drainage in patients with pancreatic ascites following ANP.

Methods

Over a period of 6 years, 12 patients (10 males; mean age: 35.9 ± 7.1 years) with pancreatic ascites following ANP underwent an attempted endoscopic drainage. Patients with a coexistent pancreatic fluid collection (PFC) underwent endoscopic ultrasound (EUS)-guided transmural drainage of PFC whereas patients with pancreatic ascites alone underwent transpapillary drainage alone.

Results

Nine (75%) patients had coexistent PFC, whereas three patients presented with ascites only. The mean size of PFC was 7.2 ± 1.6 cm. Patients with PFC underwent successful EUS-guided transmural drainage (multiple plastic stents in eight and metal stent in one patient) with complete resolution of PFC as well as ascites within 2-3 weeks. Of three patients with ascites alone, one patient had complete PD disruption, whereas two patients had partial PD disruption. Both patients with partial disruption underwent successful placement of bridging transpapillary stent and resolution of ascites at 6 weeks. In patients with complete disruption, a nonbridging stent was placed into the disruption, and ascites resolved after 8 weeks. There has been no recurrence over 27.5 ± 17.7 weeks.

Conclusion

Endoscopic drainage is a safe and effective treatment modality for the treatment of pancreatic ascites following ANP.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Complications of acute pancreatitis: clinical and CT evaluation

Mortality of acute pancreatitis is dependent on the development of potentially lethal complications that can coexist and occur at any time following an acute attack. The nature and clinical relevance of these complications differ, contingent on the time of occurrence following a severe episode of pancreatitis. They can be divided into (1), early complications that manifest at the onset or within the first 2 to 3 days, (2) intermediate complications that occur predominantly during the second to fifth week, and (3) late complications that usually manifest months or years following the resolution of an acute attack. Early complications are systemic in nature with diverse clinical manifestations of the cardiovascular, pulmonary, renal, and/or metabolic systems. Intermediate complications are abdominal, pancreatic, and retroperitoneal, and are mostly septic in nature, associated with pancreatic or peripancreatic fat necrosis and pseudocysts. Late, life-threatening complications are mainly vascular or hemorrhagic in nature or involve the development of chronic pancreatic ascites. The early detection and objective evaluation of these complications by clinical and imaging methods leads to specific treatment options in the continuous attempt to decrease mortality rates in acute pancreatitis.