Parth Desai, DO, Abdallah Masri, MD, Juan Sanchez, MD, Chimezie Mbachi, MD, Satya Mishra, MD; John H. Stroger, Jr. Hospital of Cook County, Chicago, IL
Introduction: Pancreatic fluid collections (PFCs) may complicate acute or chronic pancreatitis due to pancreatic ductal disruption, inflammation, and proteolytic activity of pancreatic secretions. Rarely, they may extend to the pleural, intraperitoneal, and retroperitoneal spaces. We report 2 rare cases of large infected PFCs extending to the iliopsoas compartment.
Methods: Case 1: A 37-year-old man with recurrent acute on chronic alcoholic pancreatitis presented with 1 week of left thigh pain and weakness. He was cachexic with a firm but non-tender abdomen and limited left leg movement. CT showed a multiloculated fluid collection near the pancreatic tail, communicating with the pleural space, and with a large retroperitoneal abscess extending inferiorly through the inguinal canal, terminating at the left anterior proximal thigh [Figure 1]. Treatment included intravenous antibiotics and drainage catheter placement. Fluid cultures grew Streptococcus anginosus. Hospitalization was complicated by aspiration pneumonia, hypoxic respiratory failure, tracheostomy and feeding tube placement. Patient was discharged home with 24-hour care. On three-month follow-up, patient had improved nutritional status. Case 2: A 71-year-old man presented to the ED with 2 weeks of tense ascites. He was hospitalized 3 weeks prior for acute biliary pancreatitis, during which he underwent ERCP and cholecystectomy. Paracentesis yielded six liters of straw-colored fluid and analysis showed 550 WBC/uL with 90% lymphocytes. Abdominal CT scan showed multiple large simple fluid loculations, the largest extending from porta hepatis down the right paracolic gutter, into the right hemipelvis [Figure 2]. Patient underwent IR-guided drainage of collected fluid, which had high amylase content and grew Enterococcus spp. The patient later developed severe right hip pain. CT showed intramuscular abscess of the right iliacus [Figure 3]. Drainage of the latter was not feasible. After continued deterioration, the patent elected for home hospice care. Discussion: PFCs can complicate pancreatitis and are usually small and spontaneously resolving that the do not require intervention. Very large PFCs have been reported invading anatomic boundaries. The presented cases illustrate the importance of broadening the index of clinical suspicion in patients presenting with vague symptoms following pancreatitis, the importance of early fluid drainage, and the poor outcome of such cases.
Figure A: Sagittal view of CT abdomen and pelvis showing multiloculated fluid collection near the pancreatic tail, communicating with the pleural space (red arrow), and with a large retroperitoneal abscess that extends through the inguinal canal to terminate at the left anterior proximal thigh (red outline), inflammatory changes and air bubbles noted. Figure B: Axial view of CT pelvis showing extension of fluid to the anterior left hip (red outline).
Sagittal view CT of the abdomen and pelvis showing large simple fluid loculations throughout the abdomen and pelvis. Largest extending from the porta hepatis of the liver down along the right paracolic gutter and into the lateral aspect of the right hemipelvis (red outline)
New thickening of the right iliacus muscle with associated stranding and loculated intramuscular abscesses (red outline)
Disclosures: Parth Desai indicated no relevant financial relationships. Abdallah Masri indicated no relevant financial relationships. Juan Sanchez indicated no relevant financial relationships. Chimezie Mbachi indicated no relevant financial relationships. Satya Mishra indicated no relevant financial relationships.