Management of acute hemorrhagic pancreatitis after EUS-guided FNA of a pancreatic cyst

Abstract

An asymptomatic 72-year-old woman underwent EUS-guided FNA of an incidental side-branch intraductal papillary mucinous neoplasm (SB-IPMN) in the head of the pancreas at an outside facility. Forty-eight hours after the procedure, she presented to our institution with severe epigastric pain, fever, jaundice, leukocytosis, and elevated lipase consistent with acute pancreatitis. CT of the abdomen andpelvis with contrast medium showed multiple peripancreatic fluid collections (PFC) around the pancreatic head. EUS showed a large PFC in the head region compressing the distal common bile duct (Fig. 1) and a pancreatic duct leak in the neck region. Because the PFC was causing obstructive jaundice, it was aspirated, revealing hemorrhagic fluid. ERCP was then performed to evaluate the pancreatic duct. A leak from a side branch in the head region was demonstrated on pancreatogram, which was bridged with a 4F 10-cm stent (Video 1, available online at www.giejournal.org). The patient also underwent jejunal feeding for 4 weeks through a nasojejunal tube, with resultant clinical improvement and resolution of the PFC on follow-up CT at 30 days. The risk of acute pancreatitis after EUS-FNA of pancreatic lesions is highest with SB-IPMN at 8%. Despite the lack of data, the use of indomethacin before EUS-FNA for pancreatitis prophylaxis can be considered in high-risk patients.