A CASE OF PANCREATIC ASCITES

Abstract

Learning Objective #1: Identify the etiology of pancreatic ascites Learning Objective #2: Manage pancreatic ascites CASE: We present a case of a 50 year-old female with a history of alcoholic cirrhosis and recurrent pancreatitis who presented to the emergency room with worsening abdominal distention for two months. Her labs were significant for elevated liver function tests, amylase and lipase. On exam, her abdomen was noted to be distended with a positive fluid wave. She underwent a paracentesis with fluid studies demonstrating SAAG < 1.1 and 4136 IU/L of amylase, consistent with an etiology of pancreatic ascites. She underwent an ERCP, which demonstrated no frank pancreatic duct leak. Given her high ascitic amylase, however, there was persistent concern for a leak and a pancreatic duct stent was placed. She continued to have worsening bilirubin, INR and creatinine but given her recent alcohol use she was deemed not to be a transplant candidate. The decision was made to enroll her into hospice, where she expired shortly after. IMPACT: This case demonstrates the importance of considering alternative etiologies of ascites in cirrhotic patients and obtaining a comprehensive work-up of new onset ascites as thei may change management. DISCUSSION: Pancreatic ascites is the accumulation of large amounts of pancreatic fluid in the peritoneal cavity. It is most commonly found in patients with chronic alcoholic pancreatitis. The exact prevalence is not yet known, but is estimated to be ~3.5% in patients with chronic pancreatitis. It can be caused by one of various mechanisms including ductal leak, pancreatic fistula and pseudocyst rupture. An elevated amylase, usually greater than 1000 IU/L, in ascitic fluid is diagnostic. Conservative management with somatostatin ana-logues, TPN and large-volume paracentesis is complicated by high failure rates. Alternatively, endoscopic treatment with pancreatic stent placement has demonstrated excellent therapeutic efficacy in patients with pancreatic ascites and is therefore considered first line therapy. Despite being the least common complication of pancreatitis, pancreatic ascites carries considerable morbidity and mortality.