Endoscopic ultrasound-guided drainage of a pancreatic abscess from duodenum

Abstract

A 56-year-old male patient presented with complaints of severe abdominal pain in the right paraumbilical region and epigastrium with fever and vomiting for 5 days. He had a history of acute pancreatitis related to alcohol before 6 weeks and had been admitted to the hospital elsewhere for 12 days. Investigations revealed a high total count of 18,700/cumm and clinically had tenderness and guarding in the right upper and paraumbilical region with fever. Computed tomography scan revealed a collection with some necrosis in the area of the C loop of the duodenum with edematous duodenal mucosa. Pancreatic duct (PD) was mildly dilated and common bile duct was prominent. Gallbladder was distended with sludge in it. We planned to assess the collection with endoscopic ultrasound and decide whether it is feasible for internal drainage or to call the surgeon. Highlights of this procedure – The puncture was possible only with a long loop position of the scope. A 19-gauge flex needle was used. He challenge was how much to dilate the cystoduodenostomy. We chose to dilate with a hurricane balloon up to 8 mm and then placed two 7 Fr double pigtail stents. We got an excellent drainage of frank pus and the pus was sent for culture and sensitivity. On follow-up, he was on intravenous antibiotics and discharged after 48 h. An ultrasound at 48 h revealed 3 ml collection. We plan to administer antibiotics for 10 days and review with magnetic resonance cholangiopancreatography at 3 weeks to see for leak and PD-stenting SOS.