Peripancreatic Collections Research Articles

An unanticipated failure of nasogastric tube placement due to peripancreatic collection: A case report

Abstract Nasogastric tube (NGT) placement is a very common clinical procedure in the emergency department (ED). The procedure is very simple, yet difficulties and catastrophes of misplacement are much more than reported. We hereby report a case of failure of the NGT placement in a patient with acute pancreatitis with a huge abdominal collection and its interesting solution. A 33-year-old male presented to ED with severe pain abdomen, abdominal distension, and shortness of breath. Abdominal examination showed a tense swelling in the upper abdomen with a grossly distended abdomen. Respiratory distress and fatigue were detected, warranting quick interventions. The reason for respiratory fatigue was figured out to be increased abdominal pressure resisting diaphragmatic pull down. As the abdomen was tense, NGT placement was to be done as part of routine care. Placement of the NGT was challenging, and multiple attempts failed to negotiate it beyond 35–40 cm, even with the best hands. An upper abdomen scan with ultrasonography (USG) point of care ultrasonography revealed hypoechoic images, likely a huge collection. A percutaneous drainage was planned immediately, a USG-guided pigtail catheter of 10 F was placed, and almost 2000 ml of fluid was aspirated. It was decided to push Ryle’s Tube (RT), and surprisingly, it was easily negotiable by now. After confirmation by the auscultation method, it was fixed at the 60 cm mark. In our case, there was compression of the stomach by the huge peripancreatic collection to the extent that there was no patent lumen to pass on anything.

A Rare Report of Carbapenem Resistant Vibrio fluvialis Isolated from a case of Walled off Necrosis: A Sequelae of Acute Necrotising Pancreatitis

Vibrio fluvialis (V. fluvialis) is commonly found in coastal environments and is an emerging pathogen encountered in diarrhoeal outbreaks and sporadic extraintestinal cases. V. fluvialis infections usually manifest as watery bloody diarrhoea, nausea, vomiting, gastroenteritis and peritonitis. In this case report, an unusual presentation of Multidrug Resistant (MDR) V. fluvialis along with Klebsiella pneumoniae co-infection from a case of Walled Off Necrosis (WON)- A complication of Acute Necrotising Pancreatitis (ANP) is discussed. The patient presented with the acute abdomen and had peripancreatic collection for which Ultrasound (USG) guided 12F pigtail drain placed over the right lower quadrant of the abdomen and conservatively managed. Routine cultures were done and the growth on Sheep Blood Agar (SBA) plate and MacConkey (MAC) agar plates were subjected for automated phenotypic identification by Matrix Assisted Laser Desorption Ionisation Time of Flight-Mass Spectrometry (MALDITOF-MS) and Vitek-2 systems and was identified as V. fluvialis. Also, molecular tests like 16S rRNA Polymerase Chain Reaction (PCR) followed by Sanger’s sequencing was done and the identification was further confirmed. Phenotypic RESIST-5 TRURAPID O.K.N.V.I. commercial lateral flow immunochromatographic assay for detection of clinically relevant and common carbapenemase genes like NDM, OXA-48, VIM, IMP and KPC was done which revealed this V. fluvialis isolate as New Delhi Metallo betalactamase (NDM) type of Carbapenemase producer. Patient was managed with levofloxacin and doxycycline and patient condition improved and was discharged.

ThP4.6 - Diagnostic Implications of Extra-biliary Revelations in Magnetic Resonance Cholangiopancreatography (MRCP) Imaging: Expanding Clinical Insights

Abstract Aim Magnetic Resonance Cholangiopancreatography (MRCP) is increasingly utilised to assess the biliary tree. The primary aim of this study was to assess the prevalence of extra-biliary findings on MRCPs. Secondary aim was to assess the need for subsequent investigations and subsequent outcomes. Methods This was a retrospective cohort study of consecutive MRCPs performed on adult patients in a single centre from November 2020 to September 2022. Patient demographics, indication(s) for MRCP, MRCP results including extra-biliary findings and subsequent investigations and outcomes were analysed from electronic case notes. Results 1,016 MRCPs were included in this study; 616 (60.6%) were for female patients and median age was 64 years (IQR 50-75). 652 (64.2%) were inpatient and 418 (41.1%) were urgent. 592 (58.3%) had at least one extra-biliary finding and 96 (9.5%) required urgent follow-up investigations with 26 (2.6%) new diagnoses of malignancy. 213 (21%) had renal cysts, 18 (11.6%) had hepatic cysts, 69 (6.8%) had pancreatic cysts, 28 (2.8%) had liver cirrhosis, 23 (2.3%) had peripancreatic collection(s), 42 (4.1%) had a hiatus hernia, 79 (7.8%) had pleural effusion(s), 46 (4.5%) had splenomegaly and 2.6% (n=26) had identified diverticular disease. Conclusions More than half of the MRCPs conducted revealed at least one extra-biliary finding. Within the findings that required urgent investigations, more than 25% had newly diagnosed malignancy. This emphasises the high sensitivity of MRCPs extends beyond biliary pathologies and can be used in diagnosing extra-biliary pathology. We suggest a structured proforma should be used by clinical radiologists for reporting MRCPs.

Peripancreatic Collection Surrounding the Portal Vein Extending to the Gallbladder in Acute-On-Chronic Pancreatitis: A Case report of a Rare Presentation of a Common Disease

Peripancreatic Collection Surrounding the Portal Vein Extending to the Gallbladder in Acute-On-Chronic Pancreatitis: A Case report of a Rare Presentation of a Common Disease

Early laparoscopic cholecystectomy in acute mild gallstone pancreatitis. Is there a role for routine admission contrast-enhanced CT Scan?

This study aims to evaluate the efficacy of admission contrast-enhanced CT scans in formulating strategies for performing early laparoscopic cholecystectomy in cases of acute gallstone pancreatitis. Patients diagnosed with acute gallstone pancreatitis underwent a CT scan upon admission (after at least 24h from symptom onset) to confirm diagnosis and assess peripancreatic fluid, collections, gallstones, and common bile duct stones. Patients with mild acute gallstone pancreatitis, following the Atlanta classification and Baltazar score A or B, were identified as candidates for early cholecystectomy (within 72h of admission). Within the analyzed period, 272 patients were diagnosed with mild acute gallstone pancreatitis according to the Atlanta Guidelines. A total of 33 patients (12.1%) were excluded: 17 (6.25%) due to SIRS, 10 (3.6%) due to local complications identified in CT (Balthazar D/E), and 6 (2.2%) due to severe comorbidities. Enhanced CT scans accurately detected gallstones, common bile duct stones, pancreatic enlargement, inflammation, pancreatic collections, and peripancreatic fluid. Among the cohort, 239 patients were selected for early laparoscopic cholecystectomy. Routine intraoperative cholangiogram was conducted in all cases, and where choledocholithiasis was present, successful treatment occurred through common bile duct exploration. Only one case required conversion from laparoscopic to open surgery. There were no observed severe complications or mortality. Admission CT scans are instrumental in identifying clinically stable patients with local tomographic complications that contraindicate early surgery. Patients meeting the criteria for mild acute gallstone pancreatitis, as per Atlanta guidelines, without SIRS or local complications (Baltazar D/E), can safely undergo early cholecystectomy within the initial 72h of admission.

Characterization of the structure of local complications of necrotic pancreatitis in the late phase using CT and MRI

Introduction: Computed tomography is the most common imaging modality used to identify necrotic collectionsin acute pancreatitis. However, using CT alone, it can be difficult to differentiate necrotic residues from the liquid component, which plays an important role in planning the intervention and predicting the outcome.Objective. To evaluate the advantages and disadvantages, as well as the specifics of the use of CT and MRI in characterizing these complications. To characterize and structure local complications of pancreatic necrosis in the late phase using CT and MRI.Materials and methods. The data of patients of the Botkin State Clinical Hospital for 2017–2022 with a diagnosis of necrotising pancreatitis, who underwent both CT and MRI after 2 weeks or more from the onset of the disease (2nd or late phase of necrotising pancreatitis), were analyzed. There are 57 people in total (34 men and 23 women), the age range is 18–71 years. CT was performed with intravenous four-phase contrast, images in the pancreatic phase were used for evaluation. MRI was performed using a standard protocol including T2-weighted images or the MRCP protocol.Results. A total of 102 peripancreatic collectionswere identified, the minimum size for evaluation was 20 mm, one patient could have more than one collection. The data obtained were structured in pairs: one collection corresponded to its images on CT and on MRI. CT showed a sensitivity of 77% with respect to dense material in the structure, while MRI revealed sequestration in all cases, sensitivity of 100%. It was possible to visualize the communication of the main pancreatic duct with accumulation on MRI in 12% of cases, on CT in 4% of cases. The identified collectionswere classified into three types based on their structure.Conclusions. CT remains the “gold standard” for the diagnosis of acute pancreatitis and necrotising pancreatitis, however, it has limited sensitivity in characterizing the structure of local complications in the late phase of the disease. Due to its greater tissue contrast MRI allows to assess the composition of peripancreatic collections and determine their possible connection with the ductal system. The types of collectionswe have identified based on CT and MRI imaging contribute to a more objective assessment of the picture in order to select the most appropriate method of patient management and the type of possible surgical treatment.

Exploring Acute Pancreatitis in Kidney Transplant Recipients: A Multicentre Retrospective Cohort Analysis of Incidence, Causes, and Clinical Outcomes.

Background: The aim of this multicentre retrospective study is to determine the incidence, etiology, clinical characteristics, and outcomes of kidney transplant recipients diagnosed and treated for acute pancreatitis. Methods: We analyzed data from kidney transplant recipients who received kidney allografts between October 1973 and December 2023 and were diagnosed and treated for acute pancreatitis. Results: Of 2482 patients who received kidney allografts, 10 (0.4%) (5 male) were diagnosed with acute pancreatitis, with a mean age of 48.6 years. Patients were diagnosed with acute pancreatitis between 3 weeks and 24 years after the transplantation. Possible etiologies included cholecystolithiasis, COVID-19, hypercalcemia, postprocedural, use of cannabis, trimetoprim-sulphometoxasole, statins, sirolimus, tacrolimus and obesity. There was no suspected etiology in two patients. Patients were treated with aggressive hydration, pain alleviation and antibiotics if indicated. Four patients developed complications. Local complications included peripancreatic collections, pseudocyst, and abscesses formation, while systemic complications occurred in the form of Cytomegalovirus (CMV) reactivation and urinary tract infection. All patients survived with preserved kidney allograft function. Conclusions: Acute pancreatitis in kidney transplant recipients is rare. However, it may be linked to significant morbidity and mortality. While symptoms may be nonspecific and brought on by a variety of viral and non-infectious illnesses, as well as adverse effects from immunosuppressive medications, a high degree of awareness is required.

To Drain or Not: Drainage Procedures Remain a Central Tenet of Management of Infected Collections in Acute Pancreatitis.

Recent literature advocates for delayed or avoidance of catheter drainage of infected peri-pancreatic collections (IPCs) in acute pancreatitis (AP). This may not be realistic for patients at academic centers, many of whom are critically ill. We retrospectively reviewed 72 patients admitted to our institution from 2016-2021 with AP and IPCs. 34.7% had a Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥3, and 56.9% had a Balthazar score of E. 65.3% were admitted to the ICU, 51.4% experienced respiratory failure, and 47.2% had acute renal failure. In-hospital mortality was 9.7%. Catheter-based drainage alone was the most frequent intervention. Only 8 individuals did not undergo any drainage. Individuals with severe AP complicated by IPCs are critically ill. Avoidance or delay of source control could lead to significant morbidity. Until further research is done on this population, drainage should remain a central tenet of management of IPCs.

Exploring the Burden and Outcome of Acute Pancreatitis: An Experience from a Tertiary Referral Center

Background and Aims: Changing trends are observed in acute pancreatitis (AP); hence, this study was conducted to determine various etiologies, severity, complications, and outcome of AP. Materials and Methods: A retrospective study was conducted on admitted 122 AP patients. Results: The male:female ratio was 1.77. The mean age was 34.11 ± 15.45 years. Various etiologies were alcohol seen in 26.2%, gallstones in 22.1%, postendoscopic retrograde cholangiopancreatography (ERCP) in 15.6%, pancreatic divisum in 4.9%, hypercalcemia in 0.8%, hypertriglyceridemia in 0.8%, viral in 0.8%, worm in 0.8%, and idiopathic in 32.8% of patients. Mild, moderately severe, and severe AP were seen in 46.7%, 36.1%, and 17.2% cases, respectively. Among local complications, peripancreatic collections were seen in 25.4%, pseudocyst or walled-off necrosis in 23.8%, ascites in 26.2%, pleural effusion in 23%, biliary obstruction in 4.9%, vascular thrombosis in 3.3%, intestinal obstruction in 3.3%, upper gastrointestinal bleed in 2.5%, and gastric outlet obstruction in 1.6% of patients. Total 27 patients had organ failure, out of which 6 had transient. Respiratory failure was the most common, followed by renal failure and circulatory failure. Percutaneous drainage was performed in 11 and endoscopic ultrasound-guided drainage in 3 patients. Mortality rate was 6.6%. Conclusions: Common etiologies of AP were idiopathic, alcohol, biliary, and post-ERCP. Mortality was 6.6% attributed to respiratory failure in severe AP.

Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study.

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

Percutaneous catheter drainage of pancreatic and peripancreatic necrotic collections: a review

Percutaneous catheter drainage of pancreatic and peripancreatic necrotic collections: a review

HPB P41 The incidence and diagnostic potential of Extra-biliary findings on Magnetic Resonance Cholangiopancreatography

Abstract Background Magnetic Resonance Cholangiopancreatography (MRCP) is increasingly utilised to assess the biliary tree. This imaging modality can potentially reveal extra-biliary findings that will warrant further urgent investigations. The primary aim of this study was to assess the prevalence of extra-biliary findings on MRCPs. The secondary aim was to assess the need for subsequent investigations and subsequent outcomes. Methods This was a retrospective cohort study of all consecutive MRCPs performed on adult patients in a single centre form September 2021 to September 2022. Patient demographics, indication(s) for MRCP, MRCP result including extra-biliary findings were analysed from electronic case notes. Further analysis of necessary investigations into these extra-biliary findings and outcomes was also undertaken. This study was registered with Clinical Quality Project (LanQIP 14742). Results 495 MRCPs were performed in the study period; 305 (61.6%) were female; median age was 63 years (IQR 50-74). 311 (62.8%) were inpatient and 200 (40.4%) were urgent. 61.2% (n=303) had at least one extra-biliary finding and 8.1% (n=44) required urgent follow-up with 12 having a new diagnosis of malignancy. 19.4% (n=96) had renal cysts, 12.7% (n=63) had hepatic cysts, 5.6% (n=28) had pancreatic cysts, 2.8% (n=14) had liver cirrhosis, 2.8% (n=14) had peripancreatic collections, 3.4% (n=17) had a hiatus hernia, 7.3% (n=36) had pleural effusions, 5.3% (n=26) had splenomegaly and 1.8% (n=9) had identified diverticular disease. Conclusions Each of the extra-biliary findings on MRCP were confirmed with further investigation, which again highlights the high accuracy of Magnetic Resonance Imaging (MRI). It is undeniable that MRCPs are revealing extra-biliary findings which indicate that the diagnosis potential of MRCPs is underestimated. Although MRIs are widely used and has no ionising radiation unlike Computerised Tomography (CT) scans, they are still more costly. Furthermore, it was also noted in previous studies that incidental findings are largely dependent on the reporting radiologist and a structured proforma might be beneficial moving forward.

Endoscopic ultrasonography-guided drainage of peripancreatic collections

Endoscopic ultrasonography-guided drainage of peripancreatic collections

Maintaining plastic stent after metal stent removal is associated with less recurrence of peripancreatic collections

Maintaining plastic stent after metal stent removal is associated with less recurrence of peripancreatic collections

FTP6.10 Acute Pancreatitis complicated with splanchnic vein thrombosis; our 12 months experience

Abstract Objectives Splanchnic vein thrombosis (SVT) is a relatively common observation in severe acute pancreatitis (AP) and is associated with pancreatic necrosis and peripancreatic collections. Currently, there is no consensus on whether patients presenting with splanchnic vein thrombosis in the setting of AP should receive therapeutic anticoagulation. We aimed to determine current practices in the management of splanchnic vein thrombosis complicating AP, in our hospital. Methods An audit of retrospectively collected data for all patients presenting with AP was conducted. Patients with splanchnic vein thrombosis were grouped according to vessel involvement and whether or not systemic anticoagulation was administered. Results Of 172 consecutive patients admitted with AP between January and December 2022, 10 had splanchnic venous thrombosis; in all cases, the thrombosis was associated with a severe attack of AP. Involvement of the splenic vein (SV), portal vein (PV) and superior mesenteric vein (SMV) was observed in 3, 2 and 3 patients, respectively. Involvement of more than one vessel was observed in two patients (SV and PV). The most common etiological factor for AP was alcohol. Seven patients received systemic anticoagulation with therapeutic LMWH initially, followed by oral DOAC for 3 months. No complications associated with systemic anticoagulation occurred. None of the patients developed liver failure, and we did not observe any fatal outcomes. Conclusions SVT represents a diagnostic and therapeutic challenge. Based on limited evidence, treatment decisions should be individualized with the evaluation of bleeding risks versus SVT recurrence or extension. Additional research is needed to further assist prompt management.

High Bowel Perforation Due Closed Abdominal Trauma in Patient with Chronic Desnutrition and Turner Syndrome. Clinical Case

Introduction: Surgical emergencies continue to be a public health problem it is estimated that 5 billion people around the world do not have access to surgery when they need it, particularly in the context of an emergency, this is even more true in countries of low economic income, low political culture and poor per capita distribution of national income, where nine out of ten people do not have access to basic surgical care. Clinical case: A 46-year-old female was admitted to the emergency department due to dyspnea and abdominal pain. She begins 7 days before her admission, with a fall from the stairs of her home. When she was admitted, she had a blood pressure of 60/40 mmHg, and significant abdominal distension, for which she began management with noradrenaline, Acute Kidney Injury was documented. A Simple Abdominal Computed Tomography was performed, which reported: Pancreas increased in size at the level of the head, peripancreatic heterogeneous collection, and free fluid in the abdominal cavity 7000 mL; Exploratory laparotomy was performed, which found: abundant purulent and intestinal fluid in the cavity, perforation of 50% of the intestinal lumen at 12 cm and denuding of the serosa at 60 cm from the angle of Treitz, pancreatic tumor; the abdominal cavity is cleaned, a pancreatic biopsy is taken. During her hospital stay, she was managed with broad-spectrum antibiotics, Parenteral Nutrition, she presented metabolic pancreatitis due to TPN 4 days after treatment, Upper Digestive Tract Bleeding that required transfusions; she began an enteral liquid diet, progressed towards improvement until her hospital discharge 19 days after surgery. The histopathological report of pancreatic biopsy reported inflammatory tissue. Discussion: Trauma patients may visit the emergency department on foot, in private vehicles, or via an emergency medical service. In Japan, ambulances are available to everyone free of charge, and the telephone triage system recommends that patients with minor injuries go to the emergency department on their own and those with serious injuries use the Emergency Medical Service.

Insulinoma: Not Anymore, A Hidden Challenge

Insulinomas comprise 1-2% of all pancreatic tumours and their small size coupled with non-specific symptomatology and an uncanny ability to go undetected on conventional imaging techniques makes preoperative localisation a diagnostic challenge. The objective is to evaluate the utility of imaging modalities and to analyse the presentation and surgical outcomes. Twenty consecutive operated cases of Insulinomas were reviewed retrospectively & prospectively over a 10year period from March 2011 to February 2021. Elevan were female & 9 male, median age was 37± 16.2 (range 21 to 50) years. The most common presentation was pre-prandial hypoglycaemia with symptomatic improvement on sugar ingestion. Biochemical diagnostic criteria used were, fasting blood glucose levels <50 mg/dl with synchronous insulin levels of >3.0 μU/ml and C-peptide levels of >0.6 ng/ml. Tumour localisation was done using a combination of CT, MRI and/or EUS in most patients and a Ga68-DOTATATE in some patients. The size ranged between 1-2 cm and their distribution was as follows: 10 in tail, 5 in body, 4 in the head of pancreas and 1 in the uncinate process. Enucleation was done in 12 patients and in 8 patients, distal pancreatectomy with/without splenectomy was done. All patients recovered uneventfully and were asymptomatic on an average follow-up of 2 years, except for one patient who developed a peripancreatic collection, detected 2 months after surgery and managed conservatively. Additionally, 2 patients had similar symptoms but were found to have nesidioblastosis and presacral soft tissue tumour. Keywords: Insulinoma, Whipple’s triad, hypoglycaemia, neuroglycopenic symptoms, enucleation.

EMPHYSEMATOUS PANCREATITIS: A RARE COMPLICATION OF ACUTE PANCREATITIS

Abstract Introduction Emphysematous pancreatitis (EP) is a serious and rare complication within the spectrum of acute pancreatitis (AP). The diagnosis is based on clinical and radiological data, that presents intraparenchymal pancreatic air in the setting of necrotizing infection. This clinical and radiological manifestation of infected pancreatic necrosis has mortality rates of over 40%. Clinical case A 71-year-old male came to the emergency department due to epigastric pain of 48h duration associated with hypotension, bradycardia with elevated pancreatic enzymes, requiring admission to the Intensive Care Unit. Initial resuscitation treatment was established, and a CT scan was performed which showed abundant air in the retroperitoneum, associated with signs of inflammation of the pancreatic gland as well as obstructive choledocholithiasis and without being able to radiologically rule out an intestinal perforation. After fluid resuscitation and stabilization of the patient, urgent surgery was performed, which showed necrosis of the entire pancreatic gland with abscessed peripancreatic collections. Wide open necrosectomy, exploration of the bile duct with extraction of lithiasis, and cholecystectomy were performed. The patient had a slow and prolonged postoperative period, progressively improving until he was discharged home. Discussion Therapeutic options for EP range from conservative management to surgery. Surgery, in these patients, is the last therapeutic step, after endoscopic or percutaneous drainage. The video-assisted retroperitoneal approach is the better procedure to be considered, since it entails less morbidity and mortality than open necrosectomy.

Acute Pancreatitis and Acute Recurrent Pancreatitis in Children: Imaging Findings and Outcomes.

The prevalence of acute pancreatitis and acute recurrent pancreatitis in children has increased over the years, and there are limited data about imaging findings. This study aimed to reveal the imaging findings of acute pancreatitis and acute recurrent pancreatitis in children at a tertiary care hospital. The patients with acute pancreatitis and acute recurrent pancreatitis diagnosed between January 2007 and December 2018 were included. Demographic and clinical features, follow-up period, and interventions were noted. Imaging features were evaluated for pancreatic enlargement, peripancreatic fluid, and biliary ducts for initial examination and pancreas parenchymal necrosis, peripancreatic collection, walled-off necrosis, pseudocyst, parenchymal atrophy, and biliary ductal dilatation for follow-up. The study included 74 patients with a mean age of 9 ± 4.9 years. The most common causes of acute pancreatitis and acute recurrent pancreatitis were biliary tract anomalies (n = 21), biliary ductal stones (n = 9), and cystic fibrosis (n = 8). Findings consistent with acute pancreatitis were determined by ultrasound in 40.5% (n = 30/74), whereas by magnetic resonance imaging in 60% (n = 39/65). Forty-one percent of the patients (n = 16) with positive magnetic resonance imaging findings did not show any findings on ultrasound. Acute recurrent pancreatitis was seen in 32 patients (43.2%). Follow-up imaging was performed in 55 patients (74.3%) between 2 months and 11 years. At follow-up, 8 patients had peripancreatic collections (6 walled-off necrosis and 2 pseudocysts). Recognizing the imaging findings of acute pancreatitis and its complications is crucial. Magnetic resonance imaging should be preferred as a second option following ultrasound, with the advantages of biliary ductal system delineation and better characterization of complications.

ODP149 Hypertriglyceridemia-Induced Acute Pancreatitis in Second Trimester of Pregnancy

Abstract Background Acute pancreatitis (AP) during pregnancy is a rare, potentially life-threatening disease, with an incidence of 1 case per 1,000-10,000. Hypertriglyceridemia (HTG)-induced pancreatitis accounts for only 5% of cases. Here we describe a rare case of HTG-induced AP during the second trimester of pregnancy, which was treated with concurrent insulin and plasmapheresis. Clinical Case A 35-year-old multigravida female was admitted for preterm premature rupture of membranes at 26 weeks gestation. Symptoms began on day 8 of admission and included severe epigastric pain radiating to the back. On exam, there was significant epigastric tenderness on palpation. There were no xanthelasmas or tendon xanthomas seen. She was afebrile but tachycardic. Laboratory evaluation noted a triglyceride (TG) level of >5,680 mg/dL (n<150), amylase 201 U/L (n<100) and lipase 277 U/L (n<60), consistent with AP. She was euglycemic. CT of the abdomen showed interstitial edematous pancreatitis with a peripancreatic collection. She was placed on NPO and started on intravenous (IV) fluid therapy, in combination with IV insulin and 10% dextrose. The patient also underwent one session of plasmapheresis. TG levels downtrended rapidly to 3,585 mg/dL within 24 hours. Once TG levels decreased below 1,000 mg/dL, insulin and dextrose infusions were stopped, and combination therapy of fenofibrate, omega-3 fatty acids, and low-fat low-carbohydrate diet was started. At 28 weeks and 5 days gestation, a cesarean section was performed due to suspected fetal distress. The patient was discharged on fenofibrate and Omega-3 fatty acids with a TG level of 456 mg/dL. Genetic testing revealed a heterozygous variant in the LPL gene mutation (c.644G>A; p. Gly215Glu) and a heterozygous variant of uncertain significance (VUS) in the ABCA1 gene (c.1765G>A; p. Val589Ile). She had no known family history of hyperlipidemia or cardiovascular disease. Conclusion Lipoprotein lipase (LPL) deficiency is an autosomal recessive disorder caused by biallelic pathogenic mutations in the LPL gene. The heterozygous c.644G>A variant has been previously described in several patients with LPL deficiency, however its impact on the function of the LPL protein has not yet been clearly defined. The ABCA1 gene is associated with Tangier disease, characterized by very low HDL levels and HTG. The ABCA1 gene variant detected in this case is classified as VUS as its effect on the gene function is not yet known. Further investigation is warranted to understand the role of these variants in familial dyslipidemia. Aside from the described patient, only one other case report of HCT-induced AP treated with concomitant plasmapheresis and IV insulin therapy has been reported in the literature. There are no published guidelines regarding the optimal treatment for HTG-induced AP in pregnancy. Combined treatment modality with plasmapheresis and IV insulin seems to be effective, however, its risks and benefits should be carefully assessed. Presentation: No date and time listed