3012 Pancreatic Ascites in a Patient With Thromboembolic Disease

INTRODUCTION: Pancreatic ascites is a rare condition characterized by abdominal pain, weight loss and progressive ascites. It is a complication of pancreatic duct disruption leading to leakage into the peritoneal cavity. The epidemiology is not well studied, which makes diagnosis challenging for clinicians. CASE DESCRIPTION/METHODS: A 54-year old female with a history of alcohol abuse, alcoholic cirrhosis, and chronic pancreatitis with pseudocyst presented to the Emergency Department with pleuritic chest pain, right calf pain and swelling for several days. She also had chronic abdominal pain, nausea, vomiting and poor appetite with 10-pound weight loss in 3 months. Her pseudocyst was routinely followed up with no significant change. The patient's significant vitals included BMI of 14.45 kg/m2, tachypnea and tachycardia. Physical examination revealed epigastric tenderness, abdominal distension and right calf swelling. Significant labs included hypoalbuminemia 1.3 g/dL, D-dimer 13.68 mcg/mL and Pro-calcitonin 19.92 mcg/L. CTA of chest revealed bilateral pulmonary emboli with right heart strain. Lower extremity duplex was positive for right femoral DVT. Patient was subsequently started on heparin infusion. A CT scan of abdomen and pelvis revealed an unchanged 2.2 × 1.1 cm pseudocyst in head of pancreas. Diagnostic paracentesis showed fluid analysis of albumin 0.5 g/dl, protein 1.4 g/dl and elevated amylase 836 U/L. The SAAG score was 0.8, which was clinical congruent with pancreatic ascites. MRCP identified the pseudocyst having a thin tubular extension along anterior pancreatic body. ERCP with pancreatic duct sphincterotomy and stent placement did not provide clinical improvement. EUS visualized a 6.6 cm fluid collection between stomach and spleen, with the pseudocyst was 1 cm adjacent to the gastric wall. It was aspirated and metal stent was placed to dilate entry into pseudocyst via endoscopic cystogastrostomy. The fluid content was finally suctioned out. The patient clinically improved and was discharged on warfarin. The stent was removed a month later. DISCUSSION: This case illustrates the importance of immediate paracentesis in diagnosing pancreatic ascites, a rare and potentially fatal condition if left untreated. Diagnosis is made with elevated fluid amylase, low SAAG score and clinical picture congruent with chronic pancreatitis with accompanied pseudocyst or severe acute pancreatitis. Early endoscopic intervention has shown highly successful at reducing mortality, hospital length of stay and recurrence.