Post-ERCP Pancreatic Phlegmon: An Uncommon Presentation of a Common Condition

Abstract

Introduction: Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), occurring in approximately 3.5% of cases. PEP with phlegmon is rarely observed in current clinical practice. We herein describe a case of severe PEP complicated by phlegmon formation presenting as acute pyelonephritis. Case Presentation: A 31-year-old female with history of cholelithiasis and non-obstructive left kidney stone presented with acute left lower abdominal pain associated with fever, nausea, and vomiting. The patient underwent an uneventful elective ERCP with negative findings 1 day prior to this visit. On examination, she had SIRS with significant CVA tenderness. Labs showed a leukocytosis of 17,600, serum lipase of 1,686 unit/L, and contaminated urine. She developed hypotension shortly after admission. An abdominal CT demonstrated acute pancreatitis with phlegmonous changes and gas in the retroperitoneum. Abscessed fluid was also identified to extend inferiorly into the left pararenal spaces. Exploratory laparotomy was emergently performed and revealed pancreatic tail necrosis complicated by an early abscess formation. The patient went through the multiple sessions of debridement and drainage during 2 months of her hospitalization. Subsequently, the patient was safely discharged home. Discussion: PEP with phlegmon formation is an extremely rare complication. In this case, extension of abscessed fluid to the left pararenal space perplexingly contributed to the typical manifestation of acute pyelonephritis. Early imaging is definitely crucial for appropriate, timely management. Hence, it is imperative for internists to be aware of common complications of ERCP, which could be presented in an uncommon fashion.