Pancreatic Ascites Managed With a Conservative Approach

A Case Report

Raju Bhandari; Rajan Chamlagain; Saraswati Bhattarai; Eric H. Tischler; Rajesh Mandal; Ramesh Singh Bhandari

Disclosures

J Med Case Reports. 2020;14(154) 

In This Article

Discussion

Pancreatic ascites refers to the massive accumulation of pancreatic fluid in the peritoneal cavity. The prevalence rate of pancreatic ascites is only 1%; it is more common in men than in women (male:female ratio 2:1) and between 20 and 50 years of age.[8] Ascites is commonly seen in patients with alcoholic liver disease and is usually a consequence of portal hypertension. Biliary pancreatitis, pancreatic trauma and cystic duplications of biliopancreatic ducts, ampullary stenosis, or ductal lithiasis account for the remainder of cases.[9] It occurs in approximately 4% of patients with chronic pancreatitis and 6–14% of patients with pancreatic pseudocysts. It may also occur after an incidence of acute pancreatitis or blunt abdominal trauma causing duct dehiscence. The diagnosis should be considered in patients with chronic ascites with a history of alcoholism, chronic pancreatitis, or abdominal trauma.[8] In 80% of cases, pancreatic ascites results from leakage from a pseudocyst in communication with the ductal system; ductal disruption in the absence of pseudocyst accounts for the remaining 20% of cases.[5]

Patients with pancreatic ascites often present with symptoms of mild abdominal pain, decreased appetite and sense of fullness, weight loss, and progressive ascites. They often present with a history of chronic pancreatitis, a recent episode of acute pancreatitis, or with new-onset ascites. However, these symptoms may be absent in alcoholics and the diagnosis may be falsely attributed to cirrhosis. Diagnosis can be made by paracentesis and analysis of the fluid for protein and amylase content. Pancreatic ascites is an exudative ascites characterized by high amylase concentration in ascitic fluid (usually over 1000 IU/L) and protein concentration over 3 g/dl, which differentiates it from cirrhosis, tuberculosis, or carcinomatosis. Rarely, the origin is indeterminate in 10% of cases. In addition to ascites, pleural effusion may be seen in such cases.[10]

Once the diagnosis has been established, abdominal CT should be done to rule out pseudocysts. The use of endoscopic retrograde cholangiopancreatography (ERCP) has been suggested to help localize ductal obstruction or the site of leakage for stenting when possible. Magnetic resonance cholangiopancreatography (MRCP) can delineate the anatomy of pancreatic duct and any abnormalities present and can be considered for candidates who cannot undergo ERCP.[11] However, the role of MRCP in the diagnosis of pancreatic ascites is not clear due to a paucity of data.

Therapy for pancreatic ascites is controversial.[8] There are no randomized control studies regarding therapy due to the rarity of the condition. A patient with pancreatic ascites may be managed conservatively withholding oral feedings and starting TPN. These minimize pancreatic secretions. One third of patients usually improve with this conservative approach while some may require treatment with octreotide or other somatostatin analogs, diuretics, and repeated paracentesis. Segal et al. conducted a prospective study to evaluate the efficacy of a long-acting somatostatin analogue called Sandostatin (octreotide) among 18 patients with either pancreatic ascites or external pancreatic fistulas (12). The ascites resolved in nine out of ten patients in a mean period of 22 days (+/&minus' 3 days). The external fistulas were all high-output fistulas and resolved in seven out of eight patients. These results indicate the value of conservative patient management.[12]

The total duration of therapy is unknown and a trial of 4–6 weeks is suggested with a consideration for interventional therapy if the condition does not resolve. This approach led to healing in less than 50% of patients and overall mortality of 15% and 15–25% recurrence.[9]

Fortunately, our patient improved with conservative management. Patients who fail conservative therapy require interventional therapy which can be either endoscopic or surgical. ERCP is a valuable tool in the evaluation of patients with pancreatic ascites to locate the site of disruption and, subsequently, placement of a transpapillary stent to bypass the obstruction in addition to large-volume paracentesis. In addition, patients can undergo concomitant endoscopic or percutaneous pseudocyst drainage.[8]

Surgical therapy is recommended when there is no response to conservative therapy in 3–4 weeks. The choice of surgery depends on the site of leakage and associated pancreatic abnormality as demonstrated by ERCP and contrast-enhanced CT. Pseudocysts are usually treated by distal pancreatectomy when the leak is in the pancreatic tail or drained by cystogastrostomy, cystojejunostomy, or cystoduodenostomy. Studies have shown that internal pancreatic drainage is the ideal surgical treatment for patients with pancreatic ascites and/or pleural effusion that do not respond to medical treatment. When this is not feasible, external drainage can be used as an alternative to pancreatic resection.[7] Fistulas in the pancreatic duct are usually drained to a Roux-en-Y jejunal loop. Recurrence rates from 50 to 64% have been reported in patients undergoing surgical intervention without ERCP.[8] Mortality rates have been reported to be similar with surgical and medical therapies (15–25%).[8]

We successfully managed our patient with a conservative approach. Our case highlights a few important messages. First, we often label the ascites as cirrhotic or secondary to portal hypertension given its high prevalence; it is important to also consider pancreatic ascites as part of the differential. As a clinician, it is important not to miss cases of pancreatic ascites. Past history or recent history of pancreatitis, recurrent admissions to an emergency room due to abdominal pain in chronic alcoholics, or history of blunt abdominal trauma may provide important guidance in diagnosing such cases. Furthermore, evaluation of the SAAG can be accurately measured to narrow the diagnosis. Paré et al. reported that SAAG calculation offers the best diagnostic discrimination between ascites caused by liver disease and ascites caused by a neoplasm.[13] Second, such cases are typically rare, and if diagnosed can be managed with medical and/or interventional therapy.

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