S1414 Successful Endoscopic Management of Necrotizing Pancreatitis Due to Rare Anatomical Variants

Abstract

INTRODUCTION: Pancreatic divisum (PD) is an embryological failure of fusion of the ventral and dorsal pancreatic ducts. Meandering main pancreatic duct (MMPD) is another rare developmental loop-type anomaly in the main duct. PD and MMPD are more prevalent in idiopathic recurrent acute pancreatitis (IRAP). We report a case of recurrent necrotizing pancreatitis in a patient with these anatomical variants, fascinatingly resulting in complete resolution after staged direct endoscopic necrosectomies. CASE DESCRIPTION/METHODS: A 51-year-old male presented with epigastric pain and vomiting. Physical examination, complete blood count, complete metabolic panel, lipase and lactic acid were unremarkable. Abdominal CT showed acute pancreatitis with 10% parenchymal necrosis and 7 × 8 × 15 cm peripancreatic walled-off necrosis. He was managed with fluids, pain and anti-emetics and tolerated diet advancement. The etiology of his pancreatitis was unclear given absence of alcohol abuse and biliary pathology and negative autoimmune work-up. He was discharged with plans to repeat imaging 6 weeks later at which time he was readmitted for fevers and pain recurrence. Abdominal CT showed increase in size of the walled-off necrosis to 15 × 10 × 20 cm (Figure 1). He was treated with antibiotics and underwent endoscopic cystogastrostomy. His clinical course was complicated by splenic vein and upper extremity deep venous thrombi and a pulmonary embolism requiring anticoagulation. While on anticoagulation, he underwent 14 careful staged endoscopic necrosectomies over two months until complete resolution (Figure 2). Subsequent ERCP demonstrated incomplete PD and reverse-Z MMPD (Figure 3). A stent was placed into the ventral pancreatic duct and he was managed with pancreatic enzyme replacement, remaining asymptomatic on 1-year follow-up. DISCUSSION: PD and MMPD are rare embryological errors, carrying ∼40% prevalence in cases of IRAP and are thought to play a role in disease onset. Necrosis complicates 20% of acute pancreatitis cases with a 25% mortality rate. While two thirds of cases resolve with conservative measures, the remainder require intervention with endoscopic necrosectomy to avoid open surgical approaches with high mortality. Large multi-center studies have demonstrated successful resolution with endoscopic necrosectomy in ∼90% of cases with significantly lower mortality. This case serves to illustrate the effectiveness of endoscopic necrosectomy even in the face of anticoagulation and to prompt physicians to consider PD and MMPD in IRAP.Figure 1.: CT showing necrotic collection.Figure 2.: Endoscopic necrosectomy.Figure 3.: ERCP showing PD and MMPD anatomical variants.