P1100 - A Rolling Stone: A Rare Case of Severe Acute Pancreatitis Caused by Obstructive Suppurative Pancreatic Ductitis

Radhika Sharma, DO, Lauren Stemboroski, DO, Barrett Attarha, DO, Bruno D. Ribeiro, MD, Ron Schey, MD, FACG
University of Florida College of Medicine-Jacksonville, Jacksonville, FL

Introduction: Acute obstructive suppurative pancreatic ductitis (AOSPD) is a rare pathology defined as purulence of the main pancreatic duct in the absence of pancreatic abscess, pseudocyst, or necrosis. AOSPD is associated with chronic pancreatitis (CP), diabetes, pancreatic stasis secondary to pancreatolithiasis or malignancy, and prior pancreatic instrumentation. Although AOSPD has been associated with CP, to the best of our knowledge there are no case reports of AOSPD causing an acute pancreatitis. We present a patient with severe acute pancreatitis caused by AOSPD secondary to a 6mm pancreatolithiasis. The patient did not have a history of CP or prior pancreatic instrumentation.

Case Description/Methods: A 58 year-old female with history of hypertension and chronic alcohol use presented to the ED with complaints of severe epigastric abdominal pain and persistent nausea and vomiting that began four hours prior. Lipase was elevated to over 2,000 and computed tomography revealed acute pancreatitis with an obstructing 6 mm calculus at the ampulla with main pancreatic ductal dilatation. The patient developed fevers of 103F, was found to have a bandemia of 38%, and was started on broad spectrum antibiotics. Endoscopic ultrasound (EUS) was performed, confirmed acute pancreatitis, and revealed a pancreatic stone in the pancreatic head. Endoscopic retrograde cholangiopancreatography (ERCP) was thereafter performed: a large pancreatic duct opening was visualized with spontaneous drainage of sludge and debris and a filling defect was seen on the pancreatogram showing a stone close to the papilla. The pancreatic duct was swept and one stone was extracted.

Discussion: AOSPD is a rare clinical entity that, in our patient, developed in the setting of pancreatic ductal obstruction secondary to pancreatolithiasis. It is hypothesized that CP, diabetes, and pancreatic instrumentation predispose to AOSPD due to pancreatic stasis and uncontrolled bacterial proliferation. Although our patient admitted to chronic alcohol use, she did not have prior history of acute pancreatitis, CP, diabetes, or pancreatic instrumentation which makes this a unique case of spontaneous AOSPD causing a severe acute pancreatitis. Diagnosis is confirmed with ERCP findings of pancreatic duct obstruction, evidence of infection through positive pancreatic fluid culture or drainage of purulent pancreatic fluid. Management of AOSPD includes fluid resuscitation, antibiotics, and emergent endoscopic decompression and drainage of the pancreatic duct.


Figure: Figure 1A: A single hyper-echoic foci measuring up to 6mm in diameter suggestive of a stone found in the pancreatic head with the pancreatic duct measuring up to 3mm in diameter. Figure 1B and 1C: The pancreatic duct was swept with a 6mm balloon; sludge was swept from the duct (1B) and one stone was removed (1C).


Disclosures:
Radhika Sharma indicated no relevant financial relationships.
Lauren Stemboroski indicated no relevant financial relationships.
Barrett Attarha indicated no relevant financial relationships.
Bruno Ribeiro indicated no relevant financial relationships.
Ron Schey indicated no relevant financial relationships.


Radhika Sharma, DO, Lauren Stemboroski, DO, Barrett Attarha, DO, Bruno D. Ribeiro, MD, Ron Schey, MD, FACG. P1100 - A Rolling Stone: A Rare Case of Severe Acute Pancreatitis Caused by Obstructive Suppurative Pancreatic Ductitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.