Pancreatic Abscess Research Articles

<i>Ochrobactrum anthropi</i>: a rare case of endocarditis

Ochrobactrum anthropi is an aerobic Gram-negative bacillus, formerly known as “Achromobacter group Vd”. It is increasingly recognized as a potentially problematic, opportunistic, and nosocomial pathogen. Most cases of human diseases due to O. anthropi are associated with central venous catheter line infection; few case reports about infective endocarditis, pancreatic abscess, puncture wound osteochondritis, endophthalmitis, urinary tract infection, meningitis, pelvic abscess, and osteomyelitis are present in the literature. Among the previously stated infections it can cause, infective endocarditis is very rare; only four cases have been described in the literature. Here, we report the case of an immunocompromised man who developed native valve endocarditis with septic cerebral embolization due to O. anthropi.

Hydatid cyst in the tail of the pancreas: a rare case report

Hydatid cysts, caused by Echinococcus granulosus, are rare but significant when found in the pancreas, particularly in endemic regions. This case report discusses a 32-year-old female with a pancreatic tail cyst presenting with epigastric pain and intermittent fever. Diagnostic imaging, contrast enhanced computed tomography (CECT) and magnetic resonance cholangiopancreatography (MRCP), and serological tests were inconclusive, making preoperative diagnosis challenging. Differential diagnoses included pancreatic pseudocysts, benign neoplasms, abscesses, and other cystic lesions. The patient underwent surgical exploration, where a hydatid cyst was identified and treated with cyst removal, partial pericystectomy, and marsupialization. Postoperative management included albendazole therapy. Pancreatic hydatid cysts, though rare, should be considered in differential diagnoses for pancreatic cystic lesions, especially in endemic areas. Accurate diagnosis typically requires a combination of imaging, serology, and histopathological examination, with surgery often necessary for definitive diagnosis and treatment.

Tuberculosis masquerading as a pancreatic cyst in a patient with cirrhosis

Cystic lesions of the pancreas are being increasingly diagnosed incidentally in recent decades due to easy availability of abdominal imaging. They may be neoplastic or benign. Tuberculosis, the great masquerader, may rarely involve the pancreas mimicking pancreatic malignancy, cyst, or abscess. Identification of this rare entity is crucial to avoid potentially risky surgery as anti-tubercular pharmacotherapy is highly effective. We report a case of a 40-year old cirrhotic man who presented with a cystic hypodense lesion in the pancreatic tail and was subsequently diagnosed with pancreatic tuberculosis. Apart from the rarity of diagnosis, our case also highlights the utility of endoscopic ultrasound for minimally invasive assessment of pancreatic lesions.

Study on the clinical effect of initiating continuous blood purification at different times for severe acute pancreatitis

To observe the clinical effect of initiating continuous blood purification (CBP) treatment at different times for patients with severe acute pancreatitis (SAP), and to explore the optimal timing for starting CBP treatment for SAP, so as to provide evidence for clinicians to start CBP treatment. A retrospective cohort study was used to select patients with SAP who received CBP treatment in People's Hospital of Hunan Province from January 2020 to December 2023. According to the timing of CBP initiation, the patients were divided into early initiation group (diagnosis of SAP to the first CBP treatment time < 24 hours) and late initiation group (diagnosis of SAP to the first CBP treatment time of 24-48 hours). The general data, acute physiology and chronic health evaluation II (APACHE II), bedside index for severity in acute pancreatitis (BISAP) score and laboratory indicators, local complications and systemic complications, intensive care unit (ICU) treatment time, hospital stay, treatment cost, and clinical outcome of the two groups were collected and compared. A total of 130 patients with SAP who received CBP treatment were enrolled, including 90 patients in the early initiation group and 40 patients in the late initiation group. Before treatment, there were no significant differences in gender, age, APACHE II score, BISAP score, etiology and laboratory examination indexes between the early initiation group and late initiation group. At 48, 72, 96 hours after treatment, the blood calcium level of the two groups was significantly higher than that before treatment, and the levels of white blood cell count (WBC), C-reactive protein (CRP), lactic acid, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), APACHE II score and BISAP score were significantly lower than those before treatment. The WBC level, APACHE II score and BISAP score of the late initiation group were significantly lower than those of the early initiation group at 72 hours and 96 hours after treatment [WBC (×109/L): 10.96 (8.68, 13.04) vs. 12.45 (8.93, 16.30) at 72 hours after treatment, and 10.18 (8.68, 12.42) vs. 11.96 (8.81, 16.87) at 96 hours after treatment; APACHE II score: 9.50 (5.75, 12.00) vs. 11.00 (6.25, 14.00) at 72 hours after treatment, and 10.00 (4.00, 12.00) vs. 12.00 (7.00, 14.75) at 96 hours after treatment; BISAP score: 2.35±1.03 vs. 2.76±1.10 at 72 hours after treatment, and 2.08±1.21 vs. 2.70±1.11 at 96 hours after treatment], the differences were statistically significant (all P < 0.05). In terms of complications, the incidence of pancreatic abscess in the late initiation group was significantly lower than that in the early initiation group [5.00% (2/40) vs. 20.00% (18/90)], but the incidence of abdominal compartment syndrome was significantly higher than that in the early initiation group [42.50% (17/40) vs. 13.33% (12/90)], the differences were statistically significant (all P < 0.05). In addition, the ICU treatment time in the early initiation group was significantly shorter than that in the late initiation group [days: 11.00 (6.00, 20.00) vs. 15.00 (9.75, 25.00), P < 0.05], and there were no statistically significant differences in hospitalization costs, length of stay and mortality between the two groups. CBP can effectively increase the level of blood calcium and decrease the level of lactic acid and inflammatory factors. Starting CBP within 24-48 hours after diagnosis of SAP can reduce WBC level and disease severity score faster, and reduce the occurrence of pancreatic abscess. Initiation of CBP within 24 hours after diagnosis of SAP can reduce the incidence of abdominal compartment syndrome and shorten the duration of ICU treatment.

Sealing the Pandora’s vase of pancreatic fistula through entrapping the digestive enzymes within a dextrorotary (D)-peptide hydrogel

A variety of therapeutic possibilities have emerged for skillfully regulating protein function or conformation through intermolecular interaction modulation to rectify abnormal biochemical reactions in diseases. Herein, a devised strategy of enzyme coordinators has been employed to alleviate postoperative pancreatic fistula (POPF), which is characterized by the leakage of digestive enzymes including trypsin, chymotrypsin, and lipase. The development of a dextrorotary (D)-peptide supramolecular gel (CP-CNDS) under this notion showcases its propensity for forming gels driven by intermolecular interaction. Upon POPF, CP-CNDS not only captures enzymes from solution into hydrogel, but also effectively entraps them within the internal gel, preventing their exchange with counterparts in the external milieu. As a result, CP-CNDS completely suppresses the activity of digestive enzymes, effectively alleviating POPF. Remarkably, rats with POPF treated with CP-CNDS not only survived but also made a recovery within a mere 3-day period, while mock-treated POPF rats had a survival rate of less than 5 days when experiencing postoperative pancreatic fistula, leak or abscess. Collectively, the reported CP-CNDS provides promising avenues for preventing and treating POPF, while exemplifying precision medicine-guided regulation of protein activity that effectively targets specific pathogenic molecules across multiple diseases.

Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess.

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole retroperitoneal space. Treatment of pancreatic abscess complicating necrotizing pancreatitis is difficult and has a high mortality rate. The well-accepted treatment strategy is early debridement of necrotic tissues, drainage, and postoperative continuous retroperitoneal lavage. However, traditional open surgery has several disadvantages, such as severe trauma, interference with abdominal organs, a high rate of postoperative infection and adhesion, and hardness with repeated debridement. The retroperitoneal laparoscopic approach has the advantages of minimal invasion, a better drainage route, convenient repeated debridement, and avoidance of the spread of retroperitoneal infection to the abdominal cavity. In addition, retroperitoneal drainage leads to fewer drainage tube problems, including miscounting, displacement, or siphon. The debridement and drainage of pancreatic abscess tissue via the retroperitoneal laparoscopic approach plays an increasingly irreplaceable role in improving patient prognosis and saving healthcare resources and costs. The main procedures described here include laying the patient on the right side, raising the lumbar bridge and then arranging the trocar; establishing the pneumoperitoneum and cleaning the pararenal fat tissues; opening the lateral pyramidal fascia and the perirenal fascia outside the peritoneal reflections; opening the anterior renal fascia and entering the anterior pararenal space from the rear; clearing the necrotic tissue and accumulating fluid; and placing drainage tubes and performing postoperative continuous retroperitoneal lavage.

Postoperative complications following neoadjuvant therapy and surgery in a phase 2 borderline resectable pancreatic cancer clinical trial (Alliance A021501).

664 Background: Postoperative complications in patients with borderline resectable pancreatic cancer treated with neoadjuvant therapy and pancreatectomy in the national cooperative group setting have not been previously characterized. Further, the impact of preoperative hypofractionated radiotherapy on postoperative outcomes is largely unknown. We sought to quantify perioperative morbidity among patients with pancreatic cancer who received neoadjuvant modified FOLFIRINOX chemotherapy with or without hypofractionated radiotherapy on a multicenter clinical trial. Methods: The A021501 phase 2 trial randomized patients with borderline resectable pancreatic ductal adenocarcinoma to 8 doses of mFOLFIRINOX (Arm 1) or 7 doses of mFOLFIRINOX then hypofractionated radiotherapy (Arm 2), followed by pancreatectomy (Dec 31, 2016-Jan 1, 2019). Patients underwent resection according to defined operative standards at enrolling centers without specific requirements for either surgeon or hospital volume. Surgical complications and adverse events were assessed and captured at a single time point of 90 days after surgery and compared between treatment arms. Results: Of 126 enrolled patients, 51 (40%) underwent pancreatectomy (n=32, Arm 1; n=19, Arm 2) at 28 institutions. Vascular resection was performed in 19 patients (37%). One patient in Arm 2 died within 90 days after surgery. Rates of any surgical complication were 19% (n=6) in Arm 1 and 42% (n=8) in Arm 2 (p=0.07). Median length of stay was 7 days (range 5-38 days). Five (10%) patients required reoperation within 90 days. Readmission rates were higher in Arm 2 than Arm 1 (16% vs. 42%, p=0.04) but there were no differences in rates of reoperation, pancreatic fistula or abscess requiring drainage, or wound infection between study arms. 54% of patients (n=26/48) experienced a grade 3 or higher adverse event, with no difference between treatment arms (47% versus 67%, p=0.7). Rates of initiation of adjuvant therapy did not differ between treatment arms (66% vs. 68%, p=0.4). Pancreatic fistula and abscess were associated with adjuvant therapy (p&lt;0.01). No difference in overall survival was observed based on occurrence of surgical complications (HR 1.1; 95% CI 0.5-2.6). Conclusions: In this national cooperative group study of patients with borderline resectable pancreatic cancer,postoperative complications following neoadjuvant chemotherapy, radiation, and surgical resection were consistent with rates previously reported by high-volume institutions and using large datasets. Multimodality trials of preoperative therapy for locoregionally advanced pancreatic cancer may be safely performed in the cooperative group setting. Clinical trial information: NCT02839343 .

Surgical complications after pancreatic transplantation: A computed tomography imaging pictorial review.

Pancreatic transplantation is considered by the American Diabetes Association and the European Association for the Study of Diabetes an acceptable surgical procedure in patients with type 1 diabetes also undergoing kidney transplantation in pre-final or end-stage renal disease if no contraindications are present. Pancreatic transplantation, however, is a complex surgical procedure and may lead to a range of postoperative complications that can significantly impact graft function and patient outcomes. Postoperative computed tomography (CT) is often adopted to evaluate perfusion of the transplanted pancreas, identify complications and as a guide for interventional radiology procedures. CT assessment after pancreatic transplantation should start with the evaluation of the arterial Y-graft, the venous anastomosis and the duodenojejunostomy. With regard to complications, CT allows for the identification of vascular complications, such as thrombosis or stenosis of blood vessels supplying the graft, the detection of pancreatic fluid collections, including pseudocysts, abscesses, or leaks, the assessment of bowel complications (anastomotic leaks, ileus or obstruction), and the identification of bleeding. The aim of this pictorial review is to illustrate CT findings of surgical-related complications after pancreatic transplantation. The knowledge of surgical techniques is of key importance to understand postoperative anatomic changes and imaging evaluation. Therefore, we first provide a short summary of the main techniques of pancreatic transplantation. Then, we provide a practical imaging approach to pancreatic transplantation and its complications providing tips and tricks for the prompt imaging diagnosis on CT.

1399. Pancreatic Abscess in Disseminated Melioidosis

Abstract Background Melioidosis is an infection caused by the gram-negative bacterium Burkholderia pseudomallei that is widely distributed in the tropical regions of Southeast Asia. It is commonly associated with intraabdominal abscesses, particularly the liver and spleen. However, there is scarce literature regarding pancreatic involvement in melioidosis. We describe a case series of pancreatic manifestations of disseminated melioidosis in a tertiary hospital in Sabah, Malaysia. Methods We conducted a retrospective case review of 63 patients with culture-positive melioidosis admitted in Queen Elizabeth Hospital, Sabah between December 2021 and March 2023 and identified cases with pancreatic involvement diagnosed by radiological imaging. Results Pancreatic involvement was reported in 3 patients (4.8%). Median duration of symptoms was 20 days. All three patients had risk factors for melioidosis (3 had poorly controlled diabetes mellitus and 1 had chronic kidney disease), and had infection involving other organs (lungs, liver, spleen and prostate). Pancreatic lesions were all detected by computed tomography scans in the tail region and ranged from small microabscesses to large solitary lesions (largest dimension 5.6 cm) with peripancreatic fat stranding. One patient required emergency hemodialysis and intensive care. Drainage of concurrent prostatic abscess was done for one patient. All 3 patients were treated with antibiotics alone (median 38 days of intensive therapy) without drainage of pancreatic abscess and showed regression of pancreatic lesions upon reassessment imaging. Patient demographic and disease details. DM, diabetes mellitus; CKD, chronic kidney disease; CT, computed tomography. Figure 1 (A) Contrast-enhanced computed tomography image showing a heterogenous hypodense lesion at the pancreatic tail (arrow) and multiple ill-defined splenic lesions (arrowhead). (B) Smaller lesions at the pancreatic tail and spleen after 35 days of antibiotics (Case 1). Conclusion Surgical drainage is required for source control of large melioidotic abscesses, however it may not be feasible for smaller pancreatic abscesses which are often multifocal and deep seated. In our study, the patients with pancreatic abscesses showed good clinical improvement with antibiotics therapy without drainage. Further studies are needed on the role of debridement for pancreatic melioidosis. Published guidelines recommend treatment of melioidosis with deep-seated abscesses with four weeks of intravenous ceftazidime as intensive therapy, followed by three to six months of oral trimethoprim-sulfamethoxazole or doxycycline as eradication therapy. Disclosures All Authors: No reported disclosures

COMPARITIVE STUDY OF PANC-3 AND BEDSIDE INDEX FOR SEVERITY IN ACUTE PANCREATITIS (BISAP) SCORING SYSTEM TO IDENTIFY SEVERITY OF PANCREATITIS

Background &amp; Objectives: Objective of this study is to evaluate accuracy and predictability of PANC-3 over BISAP scoring system to predict severity in an attack of acute pancreatitis. Methods: A total of 160 cases were enrolled in the study and was conducted in Department of General Surgery, ESICMC &amp; PGIMSR, Bangalore. All patients with clinical diagnosis of acute pancreatitis will be included in the study. It was a prospective study with study period of 18 months. Results: A total number of 160 patients were included in the study. Patients presenting with acute pancreatitis were maximum in age group of 31-40 years which included 60 patients (37.5). 153 (96%) patients were male and 4 percent (n=7) are female. Most common cause is alcohol- 124 (77.5%) patients. Next common cause is the gallstone 19 patients (11.9%). The most common chief complaint in our study was characteristic upper abdominal pain (100%) followed by vomiting (22.5%), fever (13.8%), jaundice (1.9%) and abdominal distension (1.3%). 91 patients were diagnosed to have mild acute pancreatitis, 37 patients with moderate acute pancreatitis and 32 patients with severe acute pancreatitis. All the 32 patients were correctly predicted by PANC-3 score. 11(6.9%) developed complications like pancreatic necrosis, pancreatic abscess, upper gastrointestinal bleeding, MODS, sepsis and death. 3 patients died due to complications associated with severe pancreatitis which accounts for 1.9%. Interpretation &amp;Conclusion: Our study shows that PANC-3 can be used to predict the severity of pancreatitis as efficiently as BISAP scoring. It uses only 3 criteria which are easily done and available in even the basic health care setup. The interpretation of PANC-3 does not need expertise and can be applied at the time of admission which is an advantage when compared to classical scoring systems.

Pancreatitis as a Consequence of Endoscopic Retrograde Cholangiopancreatography: A Comprehensive Review of the Literature from a Case Report

Post ERCP pancreatitis, also known as post-endoscopic retrograde cholangiopancreatography pancreatitis, is a potentially serious complication that can occur after this endoscopic procedure. It is characterized by acute inflammation of the pancreas, triggered by the manipulation and trauma induced during ERCP. This clinical condition manifests with severe abdominal pain, nausea, vomiting, bloating and fever. It varies in severity and may be associated with significant complications, such as pancreatic pseudocysts, abscesses, systemic infections, gastrointestinal bleeding, bile duct and pancreatic duct obstruction, as well as the possibility of pancreatic necrosis. Management involves a multidisciplinary approach, including supportive measures, analgesic therapy and, in severe cases, hospitalization and additional procedures such as percutaneous drainage or surgery. To prevent this complication, precautions are recommended during ERCP, such as the use of aseptic techniques, careful handling of endoscopic instruments and prophylactic use of medications. In conclusion, post-ERCP pancreatitis requires early diagnosis, an appropriate therapeutic approach and close surveillance to avoid adverse consequences and promote patient recovery.

Optimal liver transplant procedure in progressive familial intrahepatic cholestasis type 1 treated with biliary diversion or intestinal transplantation: Lessons learned from three cases treated with different approaches.

Progressive familial intrahepatic cholestasis type 1 (PFIC1) is an autosomal recessive cholestatic liver disorder caused by ATP8B1 gene mutations. Although liver transplantation (LT) is indicated for progressive liver disease, postoperative complications, including severe diarrhea and graft steatohepatitis leading to graft loss, have been reported. The first patient had jaundice, pruritus, diarrhea, and growth retardation (weight z-score: -2.5; height z-score: -3.7). She underwent LT with total internal biliary diversion (TIBD) to the colon at 2 years of age. Graft biopsy at the 7-year follow-up examination revealed microvesicular steatosis (60%). Her diarrhea improved, and her growth failure was recovering (weight z-score: -1.0; height z-score: -1.7). The second patient underwent sequential intestine-liver transplantation at 8 years of age due to end-stage liver disease (ESLD) and short bowel syndrome caused by massive bowel resection for internal hernia after partial external biliary diversion (PEBD) at 21 months of age. She developed severe pancreatitis induced by steroid-bolus therapy for rejection after transplantation. She died 1.7 years after intestinal transplantation due to an uncontrollable pancreatic abscess and acute respiratory distress syndrome. The third patient underwent PEBD at 15 months of age and received LT with TEBD at 15 years of age due to ESLD with hepatic encephalopathy. Throughout the perioperative period, she showed no abdominal symptoms, including diarrhea and pancreatitis. Graft biopsy at the 2-year follow-up examination revealed macrovesicular steatosis (60%) with inflammation. The patients showed different outcomes. Effective therapeutic options to mitigate post-LT complications in patients with PFIC1 must be considered individually.

Pancreatic cancer presenting with acute pancreatitis complicated by Wernicke’s encephalopathy and a colonic fistula: a case report

As previously noted, this is the case of a 39-year-old male patient with a BMI of 46kg/m2 who presented with acute necrotizing hemorrhagic pancreatitis. Complications developed as noted above. Multiple diagnostic imaging methods were utilized but failed to detect the presence of metastatic pancreatic adenocarcinoma. After a course of antimicrobial and nutritional therapy, we attempted surgical intervention for the pancreatic-colonic fistula and pancreatic abscess debridement. Unfortunately, during that procedure, we observed extensive carcinomatosis, at which point we did a gastrojejunostomy. Subsequently, the patient's condition did not permit chemoradiotherapy. After completion, we transferred the patient to palliative care, where he died. This case was complex due to the previously recounted results of the underlying condition, pancreatic adenocarcinoma, and the complications of Wernicke's encephalopathy and pancreatic-colonic fistula. The presence of risk factors in patients increases the need to perform appropriate diagnostic tests. Even with tests and multiple imaging modalities, these particular events remain challenging to diagnose, given the nature of the development and presentation of the disease condition. It was only after the surgical intervention that the carcinoma became evident. Early screening and imaging could improve detection rates and prevent disease progression. In this case report of acute hemorrhagic necrotizing pancreatitis and its complications, we discuss the factors making this disease process particularly difficult to diagnose, detect, and manage. Even though the complications detailed herein are rare, in this case, the significance is the need to evaluate all patients with acute pancreatitis and acute confusion for Wernicke's encephalopathy, which is preventable. In addition, suggestive findings on computed tomography signal the need for further investigation of the colonic fistula. Finally, at this time, there are no clear guidelines for the surgical management of these complications. We hope that this case report will contribute to their development.

Imaging Features of Acute Pancreatitis and the Revised Atlanta Classification System

Acute pancreatitis is a major cause of hospital admissions in the United States, with the two primary causes being gallstones and alcohol.1 The Atlanta classification system is an international classification on the severity of acute pancreatitis. In 2012, deficiencies and outdated nomenclature were removed to make a revised system that take into account advancements in research and clinical management. The revised Atlanta classification system (RACS) in 2012 standardized the nomenclature for acute pancreatitis and local complications to facilitate effective communication between clinicians and radiologists alike. Older terms such as pancreatic abscess, phlegmon, acute pseudocyst, and fluid collection are no longer used, as they are vague and can be misleading.

Pancreatic Abscess: An Infection Occurring with Minimal Tissue Present

Pancreatic Abscess: An Infection Occurring with Minimal Tissue Present

Incidence of Postoperative Complications Following Pancreatectomy for Pancreatic Cystic Lesions or Pancreatic Cancer

BackgroundIn contrast to pancreatic ductal adenocarcinoma (PDAC), the risks of pancreatectomy for mucinous pancreatic cysts (MCs) are balanced against the putative goal of removing potentially malignant tumors. Despite undergoing similar operations, different rates of perioperative complications and morbidity between MC and PDAC patient populations may affect recommendations for resection. We therefore sought to compare the rates of postoperative complications between patients undergoing pancreatectomies for MCs or PDAC. MethodsA prospectively maintained institutional database was used to identify patients who underwent surgical resection for MCs or PDAC from July 2011 to August 2019. Patient demographics, complications, and perioperative data were compared between groups. ResultsA total of 103 patients underwent surgical resection for MCs and 428 patients underwent resection for PDAC. Combined major 90-day postoperative complications were similar between MC and PDAC patients undergoing pancreaticoduodenectomy (PD, 32.5% vs. 20.0%, p = 0.068) or distal pancreatectomy (DP, 30.2% vs. 20.5%, p = 0.172). The most frequent complications were postoperative pancreatic fistula (POPF), abscess, and postoperative bleeding. The incidence of 90-day ISGPS Grade B/C POPF was higher in cyst patients undergoing PD (17.5% vs. 4.1%, p = 0.003) but not DP (25.4% vs. 20.5%, p = 0.473). No significant differences in operative time or length of stay between MCs and PDAC cohorts were observed. ConclusionsPOPFs occur more frequently and at higher grades in patients undergoing PD for MCs than for PDAC and should inform patient selection. Accordingly, the perioperative management of MC patients undergoing PD should emphasize POPF risk mitigation.

S1855 Unusual Picture of Pancreatic Abscess in a Patient With a Near-Total Distal Pancreatectomy

Introduction: Pancreatic abscess is an infection of the pancreatic pseudocyst which usually occurs 4 weeks after the onset of acute pancreatitis, meanwhile other causes include but are not limited to chronic pancreatitis, iatrogenic intra-abdominal procedures, and seeding from distant sites. We hereby report a case of an unusual occurrence of pancreatic abscess in a patient with a near-total distal pancreatectomy. Case Description/Methods: Patient is a 56-year old male with past medical history of diabetes, pancreatic adenocarcinoma, status post near-total distal pancreatectomy 6 months earlier, pancreatic pseudocyst found 3 months ago and splenectomy presented with persistent progressive worsening left upper abdominal non-radiating pain, associated with nausea, eight episodes of bilious vomiting, abdominal distension and chills. Patient denied fever. Vitals and labs were insignificant. CT scan of the abdomen showed significant increase in the size of the pancreatic cyst by the head of the pancreas with gastric outlet obstruction. Patient was started on Unasyn and the GI team proceeded to EGD/EUS and cystogastrostomy on the same day. A stent was placed [with drainage into the stomach], the cyst was aspirated, the collected purulent fluid (Figure) was sent for culture which came back positive for klebsiella pneumoniae. Patient reported relief after the procedure and was discharged on ciprofloxacin for 2 weeks. After 3 weeks, a follow-up EGD was done for necrosectomy with removal of the stent. Discussion: Pancreatic abscess is most commonly caused iatrogenically during management of necrotizing pancreatitis, however it can happen in absence of pancreatitis, secondary to biliary tract disease or duodenal disease. A high index of suspicion should be maintained in patients with acute pancreatitis, who don’t improve after initial management especially with high RANSON score, and chronic pancreatitis with persistent pain which can lead to systemic inflammatory response syndrome and death. CT is the gold standard in diagnosis with a higher sensitivity than ultrasonography, however a following fine needle aspiration, has a sensitivity of almost 100%, and is crucial to distinguish sterile inflammation from infection. Gram negative bacteria is most commonly found in aspirated fluids, however gram positive can be seen. Invasive surgical cystogastrostomy or cystoduodenostomy, depending on the location of the abscess, should not be delayed and have better outcomes than solo antibiotic therapy or endoscopic intervention.Figure 1.: Stent placement.

P438 Epidemiology, risk factor analysis and management of invasive Candida auris infections in tertiary care hepatobiliary center in India

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMObjectives Candida auris (C. auris) infections are associated with misidentification, intrahospital transmission, poor treatment outcomes, and higher mortalities. Prompt detection, earlier initiation of therapy and effective surveillance can curtail C. auris in hospitals. We aimed to study epidemiology, risk factors, and therapeutic management of invasive infections caused by C. auris in patients with hepatobiliary diseases.MethodsSingle-center, prospective study of patients with suspected invasive fungal infections between January2017-December 2021 in the patients with hepatobiliary diseases. Demographics, comorbidities, and laboratory variables were recorded. The positive yeast cultures were identified by VITEK 2 (Biomerieux, India) and antifungal sensitivity confirmed by Broth microdilution in accordance with CLSI guidelines. The final outcomes considered were mortality within 1 month after diagnosis or discharge of the patient with stable parameters.ResultsTotal of 189 isolates of C. auris from 73 patients, blood 25 (13.2%), abdominal fluids 29 (15.3%), urine 90 (47.6%), respiratory 7 (3.6%), liver abscess 2 (1.05%), pancreatic abscess 1 (0.5%), and wound infections 3 (1.5%). Underlying disease was chronic liver disease 49 (68%), 15 (20%) post liver transplant patients, acute on chronic liver failure 5 (7%), acute liver failure 2 (3%), acute pancreatitis 1 (1.3%), and pancreatic neuroendocrine tumor 1 (1.3%). 18 (25%) patients were discharged, the mortality was 54 (74.04%). Risk factors were MELD 40 (P .04), Child C (P .05), and CTP score above 12. Prior use of steroids (P .02), neutropenia (P .03), prolonged hospital stay (P .029), the use of broad-spectrum antibiotics ˃7 days (P .05) were the risk factors significantly associated with the development of C. auris infections, and higher mortality. Co-morbidities, acute renal failure, diabetes, and hepatitis infection were not significantly associated with mortality. The antifungal resistance: fluconazole 68.42%, voriconazole 14.03%, flucytosine 59.64%, and amphotericin B 28% with no resistance to caspofungin and micafungin.ConclusionOur study depicts the spectrum of invasive infections caused by C. auris, its prevalence, risk factors, and therapeutic options. The presence of risk factors, steroid use, neutropenia, broad-spectrum antibiotic use, and a hospital stay of ˃7 days should prompt toward escalating diagnostic measures for rapid identification of C. auris for early initiation of therapy. Active screening of patients with risk factors can also reduce mortality. The study results also help to guide empiric therapy with echinocandins as azoles and amphotericin B show high resistance in these isolates.

Management of pancreatic abscess following acute pancreatitis

Pancreatic abscess occurs as sequelae of acute pancreatitis. The standard treatment of infected pancreatic abscess is open surgical drainage and antibiotics. Recently, minimally invasive drainage methods such as image-guided percutaneous catheter drainage, transluminal endoscopic drainage through the stomach or duodenum, and retroperitoneal surgical drainage are becoming the trend. Open surgical drainage has a drawback of triggering a strong inflammatory response that can lead to multi-organ failure, bleeding, and gastrointestinal fistula unlike the minimally invasive approach. However, in the absence of facilities and expertise for minimally invasive drainage techniques, coupled with a patient with extensive/diffuse pancreatic necrosis and clinical deterioration, open surgical drainage may suffice. We report a case of pancreatic abscess which developed in a middle-aged man after few months of treatment and recovery from acute pancreatitis that was managed by open surgical drainage and parenteral antibiotics with good outcome.

PANCREATIC TUBERCULOSIS: A RARE DIAGNOSIS BY ENDOSCOPIC ULTRASOUND GUIDED FNAC

Introducation: Tuberculosis remains a threat to global public health and is the top infectious cause of death globally. The burden of extrapulmonary tuberculosis (EPTB) is high, ranging from 15-20% of all TB cases in HIV negative patients while in HIV positive people, it account for 40-50% of new TB cases. Abdominal TB cases makes up about 3 % of all EPTB cases in India. In abdominal tuberculosis, Ileocaecal region is most commonly affected; solid organs like kidney, spleen and liver get involved with Tuberculosis much more commonly than the pancreas. Pancreatic tuberculosis is very rare even in regions with high prevalence of tuberculosis. Pancreatic tuberculosis most commonly aficts the region of the head and the uncinate process of the pancreas. It is often misdiagnosed due to low index of suspicion and masquerading of its symptoms as pancreatic malignancy. Case Presentation: A 67 years old male presented to the physician with a history of pain abdomen in umbilical region. Ultrasound whole abdomen demonstrated mildly bulky pancreas with ill dened hypoechoic lesion in the body region. Endoscopic ultrasound-guided ne needle aspiration (EUS-FNA) of the lesion was performed and cytology revealed numerous acid fast bacilli with necrotic material in background of red blood cells. Abdominal computed tomography (CT) scan was done which was suggestive of well- dened non enhancing multiloculated lesions of body of pancreas with evidence of necrotic lymph node in pre and left para-aortic region. Antitubercular treatment was started accordingly. Conclusion: Pancreatic tubercuklosis may present as pancreatic abscess, pancreatitis,or acystic or solid pancreatic mass. The use of EUS-FNA has become essential tool in the evaluation of pancreatic lesion.