An Unusual Finding in Setting of Necrotizing Pancreatitis

Abstract

Purpose: Pancreatic cancer is the fourth common cause of cancer deaths in the U.S. It is a disease with grave prognosis and usually remains undiagnosed till advanced stages. Here we describe a case of a patient with metastatic pancreatic adenocarcinoma that got unmasked by acute gallstone pancreatitis. In this case, the question of gallstones versus underlying carcinoma as the precipitating factor for pancreatitis stays unanswered. The case also questions the imaging modalities available for the diagnosis of pancreatic carcinoma. A 60-year-old female with history of diabetes mellitus and hypertension presented to the hospital with high fever, abdominal distension and vomiting three days post-discharge after a complicated course of necrotizing pancreatitis. Patient's previous admission involved gallstone pancreatitis leading to ARDS with respiratory failure, tracheostomy and ventilator dependence, contrast-induced acute renal failure, and deep venous thrombosis. On exam she was febrile and tachycardic. The abdomen was distended with flank fullness and mildly tender diffusely with hypoactive bowel sounds. Blood work revealed leukocytosis, worsening renal function, and signs of a possible urinary tract infection. The patient was admitted to the intensive care unit for ventilator support, and placed on antibiotics for UTI. A CT scan of the abdomen showed the absence of pancreatic tissue, moderate ascites, and two organizing pseudocysts with the larger measuring 11 cm in transverse diameter impinging on the gastric outlet. The patient was started on parental nutrition due to inability to tolerate tube feeds. She was evaluated for the possibility of drainage of the pancreatic pseudocysts. However, there were no signs of infection, and no acute indication for drainage. Subsequent imaging revealed progressive expansion of the pseudocysts to approximately 15, and later, 17 cm, (Figure 1) with massive ascites and no discrete masses. Paracentesis of the ascitic fluid revealed inflammatory cells with no malignant cells. An endoscopic ultrasound showed a large pseudocyst with layering necrotic material within the cyst, diffuse bulge in the body and fundus of the stomach by the pseudocyst, and no discrete masses. She was not considered a candidate for endoscopic drainage of the pseudocysts and was thought to be a candidate for open drainage. On laparotomy, it was discovered that the patient had widespread carcinomatosis involving the pelvis, umbilicus, omentum, liver, falciform ligament, and stomach. Frozen sections of the omentum and falciform ligament indicated metastatic adenocarcinoma of primary pancreatico-biliary origin.