History Of Pancreatitis Research Articles

Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients.

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9years, men = 77.9%, BMI = 31.2 ± 6.3kg/m2) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3kg/m2; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9days, p < 0.001), EBL (32.3 ± 52.3 vs. 17.0 ± 43.1; p = 0.001), and conversion to open (6.6% vs. 0.6%, p = 0.001) were all superior with the robotic platform. Thirty-day overall morbidity (9.8% vs. 12.3%, p = 0.4), skin-to-skin OR time (84.5 ± 33.5 vs. 88.0 ± 35.3min, p = 0.2), and total OR time (129.2 ± 36.8 vs. 129.7 ± 39.7, p = 0.9) were similar between the LC and RC groups. Despite being older and having more comorbidities, Veteran patients undergoing robotic cholecystectomy experienced equivalent OR time and a moderate improvement in conversion rate, EBL, and hospital LOS compared to those undergoing conventional laparoscopy, therein demonstrating the safety and efficacy of the robotic platform for this patient population.

A Scoring System for Predicting Malignancy in Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Multicenter European Validation

Purpose: A preoperative diagnosis of the risk of malignancy for Intraductal Papillary Mucinous Neoplasms (IPMN) is important to choose the treatment. One of the tools currently in use is the Shin score that comprises five variables: age ≥60 years, history of pancreatitis, serum CA 19-9>37 IU/mL, Main Pancreatic Duct diameter ≥6mm and presence of mural nodules. The present study carries out an external validation of Shin score in a European multicenter cohort. Method: European multicenter retrospective study. All patients undergoing surgery for IPMN at 35 hospitals in Europe between 2010-2015 with histological confirmation were included. Results: Data from 567 patients were registered. Serum Ca 19.9, the presence of mural nodules and the MPD diameter were associated with the presence of malignancy (p <0.00001, p = 0.00012, and p = 0.00596 respectively). The score was significantly associated with the presence of malignancy (p <0.00001). In all patients, 64.41% of benign IPMN had a Shin score <3 and 57.34% of those with a diagnosis of malignancy had a score ≥3. The RR with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.09% and specificity of 64.44%. Conclusion: In our series, only the serum Ca 19.9, the mural nodules and the MPD diameter were associated with malignancy. Our data suggest that patients with a Shin score≤1 should be undergo surveillance, while patients with a score≥4 should undergo surgery. Treatment of patients with Shin scores of 2/3 should be individualized.

Minimally invasive approaches for pancreatic pseudocysts: robotic cystgastrostomy

Presenter: Ola Ahmed MD | Washington University, St. Louis Background: The majority of pancreatic pseudocysts resolve without the need for operative intervention. In a select few, surgery may be warranted for large cysts causing symptoms and unamenable to endoscopic or percutaneous drainage procedures Methods: We present the case of 2 patients: a 35 year old lady with a background of EtOH-related pancreatitis and a 43 year old gentleman with a history of gallstone pancreatitis. Both patients developed large symptomatic pancreatic pseudocysts that were unsuited to drain insertion because of the size of the cavity and the presence of a large amount of necrotic debris. Their symptoms of abdominal pain, fullness and early satiety persisted over an 8 – 10 week period and the patients underwent a robotic cystgastrostomy with pancreatic debridement. Results: The post-operative course for both was uneventful and one patient was discharged post-op day 1 while the second patient required a longer stay for social issues and was discharged on day 6. Conclusion: Pancreatic pseudocysts seldom require operative intervention. In a select number of patients, robotic cystgastrostomy is safe and feasible and the robotic approach can be advantageous with enhanced angulation and offering 3 dimensional views for complex retroperitoneal structures

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A Middle-aged Male with Erythema Nodosum and Polyarthritis: What can be the Diagnosis?

Pancreatic panniculitis is a rare triad of pancreatitis, panniculitis and polyarthritis. Due to underlying pancreatic disease, there is subcutaneous fat necrosis forming erythematous nodules especially in the lower extremities. This is accompanied with history of multiple joint pain. Timely diagnosis is the key to treatment, as pancreatic disease can progress rapidly causing life threatening complications. Authors hereby presented a rare case of pancreatic panniculitis in a 48-year-old male. Patient had a recent history of acute pancreatitis (alcohol induced) with development of erythema nodosum with pain and swelling in joints. Histopathological examination of the skin nodules revealed panniculitis, associated with elevated pancreatic enzymes on laboratory investigations and patient responded to anti-inflammatory medicines, thereby confirming the diagnosis of pancreatic panniculitis. He was treated with analgesics and steroids which reduced the erythematous nodules.

Spectrum of vascular complications in acute pancreatitis - challenges in management

Background: Vascular complication of pancreatitis is a rare entity. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the spectrum of manifestations, challenges in the diagnosis and management of vascular complications of acute pancreatitis. Methods: Patients who were managed for vascular complication of acute / chronic pancreatitis were retrospectively analysed from the year 2000 to 2019. Results: There were a total of 79 patients ( 71 Male:8 Female) with a mean age of 34.8 years . 27 patients had chronic alcoholic pancreatitis 27- Tropical pancreatitis , 18- acute pancreatitis , 3- idiopathic and 1 had post traumatic pancreatitis. 8 patients were managed conservatively. Selective arterial embolization was attempted in 55 of 70 (78.5%) patients and was successful in 44 of the 55 (80 %). 27 of 76 (31.5%) patients required surgery. Overall mortality was 7.8 %. Conclusion: Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.Tabled 1Table showing the statistics of the patient managed

Upper digestive hemorrage of uncertain origin: hemosuccus pancreaticus

Introduction: Upper gastrointestinal bleeding is a common cause of hospitalization, having multiples possible etiologies, being well known his mains origins, but losing sensibility in front of infrequent entities. Therefore, this article's objective is to introduce a rare, and hence, not considered differential diagnosis that should not be excluded, the Hemossucus Pancreaticus. Methods: A patient's case with upper gastrointestinal bleeding of unknow origin is presented, who has been studied through a six months lapse, in which, during his evolution he develops a hemodynamic instability state. Results: The case of a patient with a rare etiology of gastrointestinal bleeding, in which the diagnosis is reached after multiple procedures, given the ignorance of the underlying pathology, and therefore not expected. Conclusion: This entity is seen, mainly, in patient whit a history of alcoholism, chronic pancreatitis or aneurysm peripancreatic arteries. It's shown as an acute bleeding's case or, most commonly, as intermittent episodes whit the presence of melena. The current literature recommends multiple invasive and non-invasive diagnostic methods, and two therapeutic options: embolization or surgery.

РЕНТГЕНЭНДОВАСКУЛЯРНАЯ ЭМБОЛИЗАЦИЯ СОСУДОВ ПАРАПАНКРЕАТИЧЕСКОЙ ЗОНЫ В ЛЕЧЕНИИ ОСЛОЖНЕНИЙ ХРОНИЧЕСКОГО ПАНКРЕАТИТА

Goal. To improve the results of surgical treatment of chronic pancreatitis complicated by vascular pathology of the parapancreatic zone. Materials and methods. On the basis of the "Grodno University Clinic" in the department of X-ray Endovascular Surgery of the period 2010 to April 2020, were performed 16 embolizations of the arteries of the parapancreatic zone due to complications of chronic pancreatitis. Among the patients there were 13 (81.25%) men and 3 (18.75%) women. They had a history of chronic pancreatitis, which was confirmed using instrumental and laboratory research methods. One of the patients (6.25%) had a stationary aneurysm.15 (93.75%) patients had a bleeding clinic, which required urgent surgical interventions. Results. Angioembolization of the parapancreatic arteries was effective in 15 (93.75%) patients, which was confirmed by the results of control angiograms. Conclusions. The use of intraluminal embolization for vascular pathology of the parapancreatic zone in treatment of chronic pancreatitis complications is a minimally invasive and effective method.

Woman with Epigastric Pain

A 67-year-old woman presented to the emergency department with several hours of epigastric pain. She had a history of pancreatitis complicated by a pseudocyst 5 years before. On physical examination, she was afebrile, with a blood pressure of 205/110 mm Hg and pulse rate of 83 beats/min. She had marked tenderness without muscle guarding over the epigastric area. Laboratory investigations revealed a normal hemoglobin level and an elevated lipase level (111 IU/L). Although pancreatitis was suspected, the emergency physician performed point-of-care ultrasonography (Figure 1) and confirmed the diagnosis with a computed tomographic (CT) scan (Figure 2).Figure 2CT image of the abdomen showing a cystic mass (arrowhead) in the pancreatic tail with a hemorrhagic component and contrast extravasation (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pancreatic pseudocyst with intracystic hemorrhage. Emergency transarterial embolization of the posterior pancreatic artery was performed, and she was discharged uneventfully from the hospital. Pancreatic pseudocyst is a common complication of pancreatitis, but intracystic hemorrhage is a rare and potentially life-threatening condition with a mortality rate ranging from 15% to 50%.1Chiang K.C. Chen T.H. Hsu J.T. Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm.World J Gastroenterol. 2014; 20: 16132-16137Crossref PubMed Scopus (28) Google Scholar Clinical manifestations include abdominal pain, anemia, and melena.2Chiu H.H. Chen C.M. Wang K.C. et al.Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage.Am J Surg. 2006; 192: 87-88Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Delayed diagnosis may lead to complications such as rupture of the hemorrhagic pseudocyst, which can cause hemoperitoneum and shock. Angiographic embolization of the culprit artery is the mainstay of management,3Gambiez L.P. Ernst O.J. Merlier O.A. et al.Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis.Arch Surg. 1997; 132: 1016-1021Crossref PubMed Scopus (115) Google Scholar with surgical intervention reserved for refractory cases.

Predictivity of Biochemical Markers on Aetiology and Length of Hospitalisation in Acute Pancreatitis.

BackgroundAcute pancreatitis (AP) is a common cause of emergency hospital admission. Predictive value of biochemical markers including alanine aminotransferase (ALT), alkaline phosphatase (ALP), bilirubin and lipase on pancreatitis has not been fully established. This study aimed to assess the role of ALT, ALP, bilirubin and lipase levels at admission on predicting the aetiology and length of hospital stay in AP. This study also assesses quantitative high lipase as a predictor of gallstone pancreatitis (GP).MethodsAll patients above the age of 18 with a diagnosis of AP between October 2016 - 2017 were included in our study. The exclusion criteria were patients with a known history of pancreatitis or biliary disease/bile duct stones and pregnancy. This is a retrospective study performed from a prospectively collected electronic patient database at our hospital.ResultsAmong the 143 patients with AP, 50 patients were diagnosed with gallstone pancreatitis (GP) and the remaining of 93 patients suffered non-gallstone pancreatitis (NGP). Mean ALT level was significantly higher in gallstone pancreatitis (237 ± 351 IU) compared to non-gallstone pancreatitis (107 ± 162 IU; P = 0.005). ALP level was numerically high in GP (151.5 ± 186) compared to NGP (138 ± 105 IU; P = 0.64). Similar results in bilirubin level also noted in GP (35.5 ± 24.5) comparing to NGP (20.7 ± 79.6 µmol/L; P = 0.09).Raised ALT (9.3 ± 8.2 versus 3 ± 2.19 days), bilirubin (8.5 ± 2.5 versus 6.9 ± 1.19 days) and ALP levels (6.26 ± 6.1 versus 3.5 ± 10 days respectively; P = 0.05) were associated with longer hospitalisation in GP comparing to NGP. The lipase level more than 10 times the upper reference level (10-URL) was found to be associated with GP (39/50) than NGP (54/93; P = 0.027).ConclusionRaised ALT, high lipase of 10 URL levels were associated with gallstone pancreatitis. In gallstone pancreatitis, patients with high ALT, bilirubin and ALP levels had longer hospital stay.

Blockage of extracorporeal circulation during emergency surgery for fulminant infective endocarditis.

A 37-years-old man with a history of alcohol abuse and pancreatitis, presented to the emergency department with a 1-week history of progressively worsening dyspnoea with a fever up to 39°C. Echocardiography revealed bicuspid aortic valve with additional mobile structure and perforation of leaflet with acute aortic regurgitation. Due to rapidly deteriorating condition of the patient, a decision about immediate surgery was made. In the operating room, cardiac arrest in the asystole mechanism occurred. Extracorporeal circulation was turned on during direct heart massage. After opening of the aorta, the circulation was blocked by total clogging of the arterial line filter by fibrine deposits. The oxygenator was replaced which resulted a break in extracorporeal circulation lasting about 10 min. Patients survived surgery and was discharged after 6 week antibiotic therapy.

Groove pancreatitis has a spectrum of severity and can be managed conservatively

Background & aimsThe natural history of groove pancreatitis is incompletely characterized. Published literature suggests a high rate of surgery. We describe the short- and long-term outcomes in a cohort of patients with groove pancreatitis treated at our institution. MethodsMedical records of patients hospitalized in the University of Pittsburgh Medical Center system from 2000 to 2014 and diagnosed with groove pancreatitis based on imaging were retrospectively reviewed. Clinical presentation and outcomes during index admission and follow-up were recorded. ResultsForty-eight patients with groove pancreatitis were identified (mean age 53.2 years, 79% male). Seventy-one percent were alcohol abusers and an equal number were cigarette smokers. Prior histories of acute and chronic pancreatitis were noted in 30 (62.5%) and 21 (43.8%), respectively. Forty-four (91.7%) met criteria for acute pancreatitis during their index admission. Alcohol was the most common etiology (68.8%). No patient experienced organ failure. The most frequent imaging findings were fat stranding in the groove (83.3%), duodenal wall thickening (52.1%), and soft tissue mass/thickening in the groove (50%). Over a mean follow-up of 5.0 years, seven (14.6%) required a pancreas-related surgery. Patients had a high burden of pancreatitis-related readmissions (68.8%, 69.4/100 patient-years). Incident diabetes and chronic pancreatitis were diagnosed in 5 (13.9% of patients at risk) and 8 (29.6% of patients at risk) respectively. ConclusionsGroove pancreatitis has a wide spectrum of severity; most patients have mild disease. These patients have a high burden of readmissions and progression to chronic pancreatitis. A small minority requires surgical intervention.

Аберрантная поджелудочная железа: диагностика и терапевтическая тактика. Клиническое наблюдение

Aberrant pancreas is a result of impaired embryogenesis. The clinical presentation varies and mimics different diseases. The diagnostics complexity makes specialists conduct the patients’ work-up more thoroughly. Chronic recurrent pancreatitis is one of pancreatic cancer risk factors. Tobacco and alcohol consumption significantly increases the risk of developing aberrant pancreas. The article presents a clinical case of a 37-year-old man with a 10-year history of chronic pancreatitis mainly highlighting the diagnostics of aberrant pancreas. The disease manifested with an episode of acute pancreatitis and pancreonecrosis treated in a hospital. Pancreatic pseudocysts were diagnosed four years later. However, only six years after, aberrant pancreas in stomach and cystic dystrophy of duodenal wall were diagnosed. Accurate diagnosis allowed tailored treatment and avoiding surgery.

Preoperative ERCP has no impact on islet yield following total pancreatectomy and islet autotransplantation (TPIAT): Results from the Prospective Observational Study of TPIAT (POST) cohort

Background and aimsMany patients undergoing total pancreatectomy with islet autotransplant (TPIAT) for severe, refractory chronic pancreatitis or recurrent acute pancreatitis have a history of endoscopic retrograde cholangiopancreatography (ERCP). Using data from the multicenter POST (Prospective Observational Study of TPIAT) cohort, we aimed to determine clinical characteristics associated with ERCP and the effect of ERCP on islet yield. MethodsUsing data from 230 participants (11 centers), demographics, pancreatitis history, and imaging features were tested for association with ERCP procedures. Logistic and linear regression were used to assess association of islet yield measures with having any pre-operative ERCPs and with the number of ERCPs, adjusting for confounders. Results175 (76%) underwent ERCPs [median number of ERCPs (IQR) 2 (1-4). ERCP was more common in those with obstructed pancreatic duct (p = 0.0009), pancreas divisum (p = 0.0009), prior pancreatic surgery (p = 0.005), and longer disease duration (p = 0.004). A greater number of ERCPs was associated with disease duration (p < 0.0001), obstructed pancreatic duct (p = 0.006), and prior pancreatic surgery (p = 0.006) and increased risk for positive islet culture (p < 0.0001). Mean total IEQ/kg with vs. without prior ERCP were 4145 (95% CI 3621-4669) vs. 3476 (95% CI 2521-4431) respectively (p = 0.23). Adjusting for confounders, islet yield was not significantly associated with prior ERCP, number of ERCPs, biliary or pancreatic sphincterotomy or stent placement. ConclusionsERCP did not appear to adversely impact islet yield. When indicated, ERCP need not be withheld to optimize islet yield but the risk-benefit ratio of ERCP should be considered given its potential harms, including risk for excessive delay in TPIAT.

Evaluation of contrast-enhanced computed tomography for the differential diagnosis of hypovascular pancreatic neuroendocrine tumors from chronic mass-forming pancreatitis

PurposeTo assess the role of contrast-enhanced computed tomography (CECT) for differentiation of hypovascular pancreatic neuroendocrine tumors (hypo-PNETs) from chronic mass-forming pancreatitis (CMFP). MethodsA retrospective study of 59 patients (27 hypo-PNETs patients vs 32 CMFP patients) who underwent preoperative CECT between July 2012 and July 2019 was performed. Qualitative and quantitative analysis was performed, including mass location, size, margin, cystic changes, calcification, pancreatic or bile duct dilatation, pancreatic atrophy, local vessels involvement, mass contrast enhancement and mass-to-pancreas enhancement ratio. Multivariate logistic regression analyses were used to identify relevant CT imaging findings in differentiation between hypo-PNETs and CMFP. ResultsWhen compared to CMFP, hypo-PNETs more frequently had a well-defined margin and cystic changes and less frequently had a history of pancreatitis and calcification. CMFP had higher mass contrast enhancement and mass-to-pancreas enhancement ratio in the portal and delayed phases than hypo-PNETs. After multivariate logistic regression analyses, areas under the curve (AUCs) were 0.795 (95 % CI: 0.652−0.899), 0.752 (95 % CI: 0.604−0.866), 0.859 (95 % CI: 0.726−0.943), and 0.929 (95 % CI: 0.814−0.983) for Model 1(clinical factors), Model 2 (qualitative parameters), Model 3 (quantitative parameters), and their combinations, respectively. ConclusionCombined assessment of clinical factors, qualitative, and quantitative imaging characteristics can improve the differentiation between hypo-PNETs and CMFP at CECT.

Acquired Acrodermatitis Enteropathica

A 34-year-old woman with a history of chronic pancreatitis, untreated hepatitis C, depression, intravenous drug use, alcohol abuse, gastritis, and upper gastrointestinal bleed presented with a 2-month history of intractable rash, watery diarrhea, hair loss, poor oral intake, lethargy, and peripheral edema. On examination, she was noted to be cachectic, had pitting pedal edema, and had a thin, dull, erythematous plaque with a rim of desquamation located over both thighs and buttocks (extending to the gluteal cleft, sparing the anal orifice) (Figure, A and B).

S1550 Abdominal Cysts: To Drain or Not to Drain, a Rare Case of a Mesenteric Cyst

INTRODUCTION: Mesenteric cysts are rare benign intra-abdominal tumors with an incidence of approximately 1 case per 100,000–250,000 hospital admissions. This was first described in 1507 by Italian anatomist Benevenni while performing an autopsy. Unfortunately, exact etiology is still unknown, but the most accepted theory is thought to be a benign proliferation of ectopic lymphatics in the mesentery. This benign lesion has a low incidence rate, as they are considered the rarest variety between abdominal cysts. CASE DESCRIPTION/METHODS: This is a 35-year-old African American female with a past medical history of chronic cholelithiasis presented to the hospital with complaints of worsening right upper quadrant (RUQ) abdominal pain and nausea for a few months. Patient had no weight loss, or loss of appetite, and no history of alcoholism or pancreatitis. Patient was vitally stable. Exam showed mild RUQ tenderness, and a negative murphy’s sign. Labs revealed mild transaminitis with a normal serum lipase. Computerized tomography (CT) was performed, showing a large cystic mass in the RUQ measuring 10.3 × 9.8 × 11.3 cm exerting mass effect on the pancreas and gallbladder with mild intrahepatic biliary ductal dilatation. Endoscopic ultrasonography (EUS) was done for possible drainage via axios stent, but a septated cystic structure was seen. Given no history of pancreatitis and the complexity of the cyst, fine needle aspiration was performed instead, showing a bile-like fluid aspirate suggesting a possible biloma. Fluid analysis was negative for bilirubin, carcinoembryonic antigen and lipase. Patient then underwent an exploratory laparotomy which revealed a mass adherent to the gallbladder, but intra-operative cholangiogram was negative for any communication. Cholecystectomy and cyst removal were performed, and pathology was consistent with a mesenteric cyst. DISCUSSION: Mesenteric cysts are defined as any cyst in the mesentery of the gastrointestinal tract that may extend into the retroperitoneum. They can present at any age but are most seen in the second decade of life. Most are identified as painless, mobile, periumbilical masses, and treatment is usually surgical resection without drainage, if symptomatic. We present a case of an abnormally located mesenteric cyst, mimicking biliary/pancreatic pathology, and although low on the differential, one must look at the patient’s history and not assume all abdominal cysts are common and drainable, as not all abdominal cysts are created equally.Figure 1.: Computerized tomography showing a 10.3 × 9.8 × 11.3 cm cystic structure.Figure 2.: Endoscopic Ultrasonography showing a septated cystic structure.Figure 3.: Intraoperative Cholangiogram.

A RARE CASE OF EMPYEMA SECONDARY TO PANCREATICOPLEURAL FISTULA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pancreaticopleural fistula is a rare complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. CASE PRESENTATION: 50-year-old woman with alcohol use disorder and chronic pancreatitis presented with abdominal pain, vomiting and dyspnea on exertion. Serum chemistries revealed elevated lipase and amylase suggesting acute pancreatitis. Computer Tomography (CT) chest, abdomen and pelvis revealed massive left pleural effusion causing mediastinal shift to the right and multiple rim-enhancing cystic structures around the pancreas, suggestive of pancreatic pseudocysts. Pleural drainage was performed with a chest tube placement, after which patient reported symptom relief. Pleural fluid analysis revealed an exudative pattern with elevated amylase, reflecting likely pancreatic etiology, and raising suspicion of pancreaticopleural fistula (PPF). Following pleural fluid drainage and aeration of the lung, she developed fever with leukocytosis; repeat CT chest revealed multi-loculated pleural effusion. A working diagnosis of empyema secondary to (PPF) was made and patient was started on intravenous (IV) antibiotics. Magnetic resonance cholangiopancreatography (MRCP) revealed walled off necrosis surrounding the pancreatic tail extending into the left subdiaphragmatic and left pleural spaces, confirming the diagnosis of (PPF). She underwent Endoscopic retrograde cholangiopancreatography (ERCP) without successful cannulation of pancreatic duct. Partial distal pancreatectomy was performed with resolution of pleural effusion and symptoms. DISCUSSION: PPF is usually a consequence of leak from an incompletely formed or ruptured pseudocyst or from direct pancreatic duct leak either through the esophageal hiatus or the diaphragm into the pleural space. It typically presents with pulmonary symptoms more than the abdominal symptoms. Left-sided pleural effusion is typical, though right-sided or bilateral effusions are not uncommon. Empyema, a known major complication that can lead to life threatening sepsis, occurs when there is an ascending infection via the fistulous tract. Diagnosis is based on clinical suspicion; elevated amylase in pleural fluid strongly supports the diagnosis. MRCP is a useful diagnostic modality demonstrating the fistula. Initial management consists of pleural drainage and tube thoracotomy placement. Minimally invasive thoracic surgery with pleural debridement can also be considered. Definitive management of fistula is accomplished with stent placement via ERCP, though if that fails, surgical intervention with pancreatectomy is considered, as described in our case. CONCLUSIONS: A high index of clinical suspicion is needed for diagnosis of PPF in patients presenting with dyspnea and history of pancreatitis or its risk factors Reference #1: Schweigert M, Renz M, Dubecz A, Solymosi N, Ofner D, Stein HJ. Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management. Thorac Cardiovasc Surg. 2013;61(7):619-625. doi:10.1055/s-0033-1334996 Reference #2: Machado NO. Pancreaticopleural fistula: revisited. Diagn Ther Endosc. 2012;2012:815476. doi:10.1155/2012/815476 DISCLOSURES: No relevant relationships by Ibrahim Asghar Abid, source=Web Response No relevant relationships by Lakshmi Priyanka Mahali, source=Web Response No relevant relationships by Noa Tal, source=Web Response

S1567 Pancreatico-Pleural and Enteric Fistulas: A Rare Complication of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

INTRODUCTION: Pancreatico – pleural and enteric fistulas (PPEF) are rare complications of pancreatitis, where a tract is created draining pancreatic fluid into the pleural cavity and/or bowel. Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a 5-10% risk of pancreatitis. CASE DESCRIPTION/METHODS: A 66-year-old female with past medical history of hypertension and asthma presented for abdominal pain with nausea and vomiting. One-day prior she underwent an ERCP. She was treated conservatively for post-ERCP (pERCP) pancreatitis. Subsequently she was admitted for pancreatitis three times over a period of 3 months. Vitals were within normal limits. Physical examination was significant for diffuse abdominal tenderness and normoactive bowel sounds. Laboratory data was significant for a lipase of 2858, and a WBC of 12.39. Otherwise, complete metabolic panel, and CBC were normal. Initial computerized tomography (CT) showed acute pancreatitis with a large pseudocyst (Figure 1). Interval CT showed pancreatic duct dilation, a pancreatico-enteric fistula tract and a new left pleural effusion with air within the fluid suggestive of a pancreatico-pleural fistula (Figure 2). The patient was managed conservatively. At 3-month follow up, the patients symptoms had resolved, and a repeat CT showed resolution of pancreatitis, fistula and pleural effusion (Figure 3). DISCUSSION: Magnetic resonance cholangiopancreatography is the diagnostic imaging of choice for visualizing pancreatic fistulas. Thoracentesis with a lipase-rich pleural fluid can help aid in the diagnosis.Modalities of treatment are endoscopic stenting of the disrupted pancreatic duct, conservative management with octreotide (to suppress pancreatic exocrine function) with or without chest tube drainage, or surgical intervention with distal pancreatectomy and pancreatico-jejunostomy in those with complete ductal obstruction. Thirty to 60% of patients can be managed successfully with conservative management. Sphincter of oddi dysfunction, young age, repeated cannulation attempts with sphincterotomy, and history of pancreatitis are risk factors for pERCP pancreatitis. Prophylactic rectal indomethacin and pancreatic stenting in patients at high risk of pERCP pancreatitis have been shown to decrease incidence rates. PPEF uncommonly arise together and require a high index of suspicion. The diagnosis can be made via imaging, endoscopy or with a thoracentesis. Management is usually conservative, but endoscopic or surgical procedures may be warranted.Figure 1.: CT abdomen and pelvis showing acute pancreatitis with a pancreatic tail/body large pseudocyst (Green arrow).Figure 2.: Interval CT Chest, abdomen and pelvis showing dilated pancreatic duct (Blue arrow), resolving pancreatic pseudocyst(White arrow), pancreatico-enteric fistula tract (Red arrow), and a new left pleural effusion with air within the fluid (Yellow arrow) suggestive of a pancreatico-pleural fistula.Figure 3.: A 3-month Interval CT abdomen, pelvis and chest showing complete resolution of acute pancreatitis and fistula tract (Panel A), and resolution of pleural effusion (Panel B).

PANCREATICO-PLEURAL FISTULA AND SUBSEQUENT FUNGAL EMPYEMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A rare pancreatitis complication is pancreatico-pleural fistula with empyema development being even more scarce. CASE PRESENTATION: A 48-year-old male with a history of alcoholic pancreatitis, subsequent mediastinitis with recurrent pleural effusions and pneumonia presented to the outpatient pulmonology office for persistent dyspnea. We ordered basic labs, showing significant leukocytosis and anemia, and a thoracentesis, removing 600 milliliters. Upon transferring to the hospital, further workup revealed elevated lipase and C-reactive protein. Pleural fluid studies indicated an amylase-rich exudative process. Chest-x ray showed bilateral pleural effusions and multilobar pneumonia. Computed Tomography (CT) Angiography of chest showed loculated moderate right and small left pleural effusion, multilobar pneumonia especially in lower lobes. CT of abdomen/pelvis showed acute pancreatitis and pancreatic cystic lesions in the head and uncinate process. We initiated broad coverage with Vancomycin, Cefepime, and Metronidazole. On day 3 of admission, a chest tube was placed and 6 doses of lytic therapy were administered. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was performed and confirmed pancreatico-pleural fistula (PPF). Thus, sphincterotomy was performed and a stent was placed; however, the pancreatic duct could not be cannulated. Video-Assisted Thoracoscopic Surgery was not indicated at this time. Pleural fluid cultures grew Candida Albicans and Micafungin was added. Upon receiving sensitivities, we discontinued the current regimen and started Fluconazole. Chest tube was removed on day 10 of admission. The patient was discharged home with instructions to continue Fluconazole for 6 weeks, weekly lab monitoring, repeat ERCP with pancreatic duct cannulation in 3 weeks, and repeat Chest x-ray in 2 months. DISCUSSION: PPF with pleural effusion is reported with an incidence of 0.4%. A pancreatic duct disruption causes persistent leakage of pancreatic secretions. Initially, a fluid collection forms, known as a pseudocyst. Eventually, the secretions can cause a spontaneous erosion into a neighboring organ or cavity, the pleural cavity in our case. Patients with PPF present similarly to pleural effusions, as they are recurrent and refractory to repeated thoracentesis. 1 In rare cases, an empyema can develop that can cause life-threatening sepsis. 2 Classical PPF patients are middle-aged men, chronic pancreatitis from alcoholism, dyspneic, no acute abdominal symptoms, left pleural effusions, pseudocyst on CT, and elevated pleural fluid amylase, lipase, and albumin. These were observed in our case, except bilateral pleural effusions, which has a 19% incidence compared to 74% for left sided. 1 CONCLUSIONS: As clinicians, we should consider the rare complications of PPF in the differential for patients with a history of pancreatitis presenting for dyspnea and sepsis. Reference #1: Machado, NO. Pancreaticopleural Fistula: Revisited. Diagnostic and Therapeutic Endoscopy. 2011;2012:1-5. Reference #2: Kim E, Ahn HY, Kim YD, Hoseok, Cho JS. Successful Diagnosis and Treatment of a Pancreaticopleural Fistula in a Patient Presenting with Unusual Empyema and Hemoptysis. Korean J Thorac Cardiovasc Surg. 2019;52(3):174-177. doi: 10.5090/kjtcs.2019.52.3.174. DISCLOSURES: No relevant relationships by Jacob Burch, source=Web Response No relevant relationships by James Choi, source=Web Response No relevant relationships by Rakesh Gami, source=Web Response No relevant relationships by Tyler Kemnic, source=Web Response No relevant relationships by Jason Liu Liu, source=Web Response No relevant relationships by Rohan Prasad, source=Web Response No relevant relationships by Fazal Raziq, source=Web Response No relevant relationships by Eric Smith, source=Web Response