Julian Remouns, DO1, Muhammad Farhan Ashraf, MBBS1, Cassidy Alexandre, MD1, Muhammad Sohail Mansoor, MD1, Sajid Hussain, MD2, Domenico Viterbo, MD, PhD2; 1Albany Medical Center, Albany, NY; 2Albany Gastroenterology Consultants, Albany, NY
Introduction: Acute necrotizing pancreatitis (ANP) occurs in 20% of patients with acute pancreatitis and has a mortality rate up to 30%. Collections of solid and liquid debris can expand from the initial area of necrosis over 3-6 weeks. When encapsulated this area is called organized or walled-off pancreatic necrosis (WON) which can be aseptic or infected. 50% of patients present with symptoms and a complicated clinical course. We present a case of WON with multiple complications despite appropriate medical management.
Methods: A 34yo male with a history of EtOH abuse presents with fever, nausea, vomiting, LUQ and back pain 2 months after hospitalization for ANP complicated by ARDS and ARF. Since his previous hospitalization, he was evaluated at an OSH for abdominal pain where he was found to have a 21x27cm WON. A percutaneous drain was placed which improved his pain but continued to produce copious brown necrotic fluid. On presentation, CT abdomen showed decreased size of WON but suggested a 2nd fluid collection compressing his left ureter. Despite normal labs, IV antibiotics were started. EUS showed 100mm diameter cystic lesion in the pancreatic body/tail communicating with his drain. A cystogastrostomy (CG) was created and necrosectomy was performed. Repeat EGD showed the CG partially obstructed with necrotic tissue. Obstruction was removed and extensive necrosectomy was performed, another one done 1 week later. After 3 weeks, the patient presented again with fevers and abdominal pain. CRP was elevated. CT abdomen showed interval decrease of WON. An outpatient endoscopic necrosectomy was performed after his discharge during which a 15mm WON-to-duodenum fistula with occluding necrotic tissue with pus was found. IV antibiotics was started and hepatobiliary surgery was consulted. Discussion: Our patient promptly received serial endoscopic necrosectomies for his WON. As a result, he developed intestinal fistulization and infection, complications known to arise after such procedures. According to the AGA, this management was appropriate for him due to decreased morbidity and mortality compared to other approaches such as percutaneous drainage or open necrosectomy. Despite these recommendations, there is limited data to effectively analyze the risks and benefits of alternative strategies. This case demonstrates the complexity in managing the multiple complications of ANP as well as the importance of continued review of WON management to ensure better clinical outcomes.
Removal of necrotic tissue
View 1 of duodenal fistula
View 2 of duodenal fistula
Disclosures: Julian Remouns indicated no relevant financial relationships. Muhammad Farhan Ashraf indicated no relevant financial relationships. Cassidy Alexandre indicated no relevant financial relationships. Muhammad Sohail Mansoor indicated no relevant financial relationships. Sajid Hussain indicated no relevant financial relationships. Domenico Viterbo indicated no relevant financial relationships.