Rupture Of Pancreatic Duct Research Articles

Minimally invasive treatment of an internal pancreaticopleural fistula with massive pleural effusion: a case report

BackgroundA pancreatic duct rupture can lead to various complications such as a fistula, pseudocyst, ascites, or walled-off necrosis. Due to pleural effusion, pancreaticopleural fistula typically causes dyspnea and chest pain. Leaks of enzyme-rich pancreatic fluid forming a pleural effusion can be verified in a thoracocentesis following radiological imaging such as computed tomography or magnetic resonance tomography. While management strategies range from a conservative to endoscopic and surgical approach, we report a case with successful minimally invasive treatment of pancreaticopleural fistula and effusion.Case presentationWe present a case of a patient with pancreaticopleural fistula and successful minimally invasive surgical treatment. A 62-year old Caucasian man presented with acute chest pain and dyspnea. A computed tomography scan identified a left-sided cystoid formation, extending from the abdominal cavity into the left hemithorax with concomitant pleural effusion. Pleural effusion analysis indicated significantly elevated pancreatic enzymes. Magnetic resonance cholangiopancreatography revealed a rupture of the pancreatic duct and nearby fluid accumulation. Endosonography later confirmed proximity to the tail of the pancreas, suggesting a pancreatic pseudocyst with visible tract into the pancreas. We assumed a pancreatic duct rupture with a fistula from the tail of the pancreas transdiaphragmatically into the left hemithorax with a commencing pleural empyema. A visceral and parietal decortication on the left hemithorax and a laparoscopic distal pancreatectomy with splenectomy was performed. The suspected diagnosis of a fistula arising from the pancreatic duct was confirmed histologically.ConclusionPancreaticopleural fistulas often have a long course and may remain undiagnosed for a long time. At this point diagnostic management and therapy demand a high level of expertise. In instances of unclear symptomatic pleural effusion, considering an abdominal focus is crucial. If endoscopic treatment is not feasible, minimally invasive surgery should strongly be considered, especially when located in the distal pancreas.

EUS-guided pancreatic duct drainage: a single-center observational study

Background and aimsPancreatic duct obstruction can cause pain and atrophy of the pancreatic parenchyma. Endoscopic drainage is the first-line treatment, usually by endoscopic retrograde cholangiopancreatography. However, in some patients, the classic transpapillary approach cannot be performed because of anatomical inability to access the papilla, rupture of the main pancreatic duct, intracanal stones that cannot be crossed or tight stenosis of the main pancreatic duct due to extrinsic compression by parenchymal calcifications. Endoscopic ultrasound-guided pancreatic duct drainage is an efficient and minimally invasive therapeutic alternative for these patients. We aimed to evaluate clinical success of endoscopic ultrasound-guided pancreatic duct drainage in our center. MethodsData of patients who underwent endoscopic ultrasound-guided pancreatic duct drainage in our center between 2016 and 2022 were retrospectively reviewed. Clinical success was defined as pain ≤2 on the pain Visual Analog Scale (VAS, 0-10) and no recurrence of obstructive pancreatitis after successful stent placement. If the indication to the procedure was chronic pancreatitis with painless weight loss, then clinical success was defined as weight stabilization or weight regain after the procedure. Results46 patients (mean age 58 years old, 69.6% male) were included. Indications of endoscopic ultrasound-guided pancreatic duct drainage were chronic pancreatitis in 69.6% of patients (78.1% due to alcohol abuse). Other indications included post-operative complications, rupture of pancreatic duct and pancreatic cancer. Technical success was achieved in 93.5% of patients. 40 patients had pancreaticogastrostomy and 3 patients pancreaticoduodenostomy. The mean hospital stay was 2 days. Clinical success was 93% in patients who achieved technical success. Remaining pain on the VAS > 2 occurred in 9.3% of patients and obstructive pancreatitis recurrence in 6.9%. Adverse event occurred in 5 patients (11.6%). 18 stent dysfunctions were observed, 16 stent migrations and 2 stent obstructions. No patient died from the procedure. ConclusionEndoscopic ultrasound-guided pancreatic duct drainage showed a high clinical success rate. It is therefore a good minimally invasive alternative to avoid pancreatic surgery in patients with symptomatic pancreatic duct stenosis of benign or malignant etiology who failed endoscopic retrograde cholangiopancreatography.

Usefulness of endoscopic pancreatography without contrast agents and efficacy of transpapillary intervention for pancreatic duct rupture in chronic pancreatitis: Our study of 321 cases in 11 years

Pankaj N. Desai, Chintan N. Patel, Mayank V. Kabrawala, Subhash K. Nandwani, Rajiv M. Mehta, Ritesh M. Prajapati, Nisharg B. Patel, Krishna K. Parekh, and Neha D. Sheth. Int J Gastrointest Interv 2021;10:1-5. https://doi.org/10.18528/ijgii200029

Intraductal tubulopapillary neoplasms with rupture of the distal main pancreatic duct: a case report

BackgroundIntraductal tubulopapillary neoplasm (ITPN) is a rare and newly described entity defined as an intraductal, grossly visible, tubule-forming epithelial neoplasm with high-grade dysplasia and ductal differentiation without overt production of mucin. Because of its rarity, the clinical and molecular aspects of ITPN have not been fully investigated.Case presentationA 73-year-old woman presented to a local hospital with epigastric discomfort and pain. Abdominal multidetector-row computed tomography (MDCT) revealed a 2.5-cm hypovascular tumor in the pancreatic body with distal pancreatic duct dilatation and a slightly low-density area spreading over the ventral side of the pancreatic body. Endoscopic ultrasonography and fine-needle biopsy of the tumor revealed adenocarcinoma of the pancreas. She was referred to our hospital 2 months later. MDCT performed at our hospital showed no significant change in the tumor size or pancreatic duct dilatation. However, the low-density area at the ventral side of the pancreas had shrunk; therefore, this finding was considered to have been an inflammatory change. Under a preoperative diagnosis of resectable pancreatic ductal adenocarcinoma, distal pancreatectomy was performed. The final diagnosis was ITPN with associated invasive carcinoma. Macroscopically and microscopically, the main pancreatic duct (MPD) had ruptured at the distal side of the tumor, and the fistula connected the MPD and extrapancreatic scar tissue.ConclusionsITPN with rupture of the pancreatic duct is extremely rare. In the present case, a sudden increase in the pancreatic duct internal pressure or acute inflammation likely caused the rupture of the MPD.

Traumatic pancreatic duct rupture: Percutaneous drainage

Traumatic pancreatic duct rupture: Percutaneous drainage

Isolated and complete traumatic rupture of the pancreas: A case report and a review of the literature

INTRODUCTIONPancreatic trauma without injuries to other organs is uncommon, as reported in the reviewed literature. Diagnosis of pancreatic trauma might be difficult, due to unspecific signs and symptoms. The integrity of the main pancreatic duct is the crucial point in the management and outcome of patients with pancreatic trauma. PRESENTATION OF CASEThe authors report a case of delayed diagnosis after a complete traumatic rupture of the main pancreatic duct, successfully managed by surgical treatment. The authors performed a laparotomy with complete removal of necrotic pancreatic tissue at the site of rupture. The proximal pancreatic stump was hand-sewn with detached stitches and a disposable catheter was positioned into Wirsung's duct, a diversion of the distal stump with a Roux-en-y pancreato-jejunal anastomosis was performed. The postoperative course was uneventful. DISCUSSIONTraumatic injuries of the pancreas occur after blunt abdominal traumas or penetrating wounds with a ratio of 3:1. Isolated traumatic injuries of the pancreas are uncommon; and they are usually associated with injuries to other organs. Surgical solutions for the treatment of pancreas lesions vary and it is well known that a surgical procedure performed after a delayed diagnosis is associated with high mortality and morbidity, especially in pancreatic duct rupture. CONCLUSIONPancreatic trauma is a diagnostic and therapeutic challenge for the trauma surgeon. The integrity of the main pancreatic duct is the most important determinant of outcome after injury to the pancreas and, in Wirsung's duct rupture, early surgery may improve it.

Prise en charge chirurgicale de la pancréatite chronique

Surgical indications for chronic pancreatitis can be schematically separated into five main groups: pain, effects of fibrosis on adjacent organs, the consequences of main pancreatic duct rupture above an obstruction, and suspected cancer. Finally surgery is also indicated in patients who cannot undergo endoscopic procedures (no accessible papilla) or who have too recently undergone this procedure. Surgical procedures include derivation (pancreatic, cystic, biliary) or mixed procedures combining derivation/resection or pancreatic resection. Finally splanchnicectomy can be discussed. Whatever the indication, surgical treatment must meet several goals: the approach to surgery must be multidisciplinary, surgery must be associated with low morbidity and mortality, preserve as much endocrine function as possible, improve quality of life, and be evaluated in the long term, as well as prospectively if possible. We clarify some important points about the management of patients with chronic pancreatitis before discussing the various treatments in detail.

Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging

Diagnosis of internal pancreatic fistulae (IPF) resulting in ascites or pleural effusions may be facilitated by multislice helical CT-scan and MR-pancreatography [MRP]). Conservative treatment with parenteral nutrition and somatostatin analogues (+/- pancreatic stenting) yields varying results. We aimed to evaluate the usefulness of helical CT and MRP in the diagnosis of IPF. The outcome of patients when the following stepwise treatment algorithm is applied is also descried: i) conservative (enteral nutrition and somatostatin analogues); ii) endoscopic stenting; iii) surgery. Sixteen consecutive patients (13 M; median age 42 (14-54) yrs) with chronic pancreatitis (alcoholic 15, hereditary 1) and an IPF were prospectively included between March-01 to December-03. All serous effusions (ascites, N=10; pleural effusion, N=6) contained high lipase [median: 7800 (506-59000) U/mL]. Patients with fistulae communicating with pancreatic pseudocysts were not included. The diagnosis of IPF and its site were determined in 12/16 patients by CT and 14/15 patients by MRP (site of rupture: head: N=5; isthmus: N=5; body-tail: N=6) and confirmed by ERCP or surgery in 9. Localized atrophy of pancreatic parenchyma adjacent to pancreatic duct rupture was observed in 12 patients (75%). The median follow-up was 30 months (18-51). Early surgery was required in 3 patients (2 with infection of serous fluid at initial aspiration analysis). Thirteen entered the treatment algorithm: - seven patients responded favorably (54%) to conservative treatment (enteral nutrition and somatostatin analogues); - pancreatic stenting, possible in 4 of 6 patients, was successful in closing the IPF in 2; - surgery was required in the 4 remaining patients. Preoperative localization of the rupture site was possible in all patients using non-invasive imaging thus guiding elective intervention in all patients requiring surgery. Helical CT scan and MRP are useful in localizing MPD rupture sites and fistulae and may obviate the need for pancreatic opacification. A systematic treatment algorithm can be safely used starting with medical strategies (enteral nutrition safely replacing the parenteral route) progressing to endoscopy and finally surgery. Overall about 44% of patients require surgery initially or at follow-up.

Endoscopic Treatment of External Pancreatic Fistulas: When Draining the Main Pancreatic Duct Is Not Enough

Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs. Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described. All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment. Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.

Right intrahepatic pseudocyst following acute pancreatitis: an unusual location after acute pancreatitis

The location of a pseudocyst (PC) in the liver is an exceptional event, and intrahepatic PCs are mainly located in the left lobe. We report here a case of right intrahepatic PC following acute pancreatitis associated with cystic (aberrant pancreatic) dystrophy of the duodenal wall (CDDW) and chronic pancreatitis. Morphological assessment (ultrasound, computed tomography [CT] scan, and cholangio-magnetic resonance imaging [MRI]) revealed a 10-cm right intrahepatic collection and rupture of the main pancreatic duct. Percutaneous puncture permitted us to detect a high level of amylase in the collection, confirming the diagnosis of intrahepatic PC. Surgical drainage concomitant with pancreatico-duodenectomy for the treatment of CDDW resulted in disappearance of the collection. The mechanism involved in this patient was rupture of the pancreatic duct in the retroperitoneal cavity and erosion reaching the right hepatic parenchyma. Although intrahepatic PCs are rare, the diagnosis of intrahepatic PC complicating acute pancreatitis can be confirmed by a high level of amylase in the collection. Asymptomatic intrahepatic PCs can be treated conservatively, and symptomatic intrahepatic PCs can be managed either transcutaneously or surgically.

Pancreatic Injury from Blunt Abdominal Trauma in Childhood

Background : Pancreatic trauma in children is relatively uncommon, but carries high morbidity and mortality rates when diagnosis is delayed. Preoperative diagnosis of pancreatic lesion might be difficult, especially in the case of isolated injury.Methodology : Authors analyse seven cases of pancreatic trauma in childhood. In three cases surgical intervention was required due to pancreatic transection with main pancreatic duct rupture. The injuries of the 5–10 years old male patients were diagnosed and operated on within 24 hours.Results : In two cases distal resection were performed with splenic preservation. In one case-where the operation was performed within 8 hours-preservation of the distal pancreas was also achieved by distal pancreatogastrostomy. The postoperative period was uneventful in all cases. Impaired glucose metabolism was not found in the operated cases during the follow up.Conclusions : Authors emphasise the importance of CT scan and the responsibility of the first attending physician regarding both diagnosis and correct surgical management.

Endoscopic Treatment for Main Pancreatic Duct Rupture Following Silastic Ring Vertical Banded Gastroplasty

Endoscopic Treatment for Main Pancreatic Duct Rupture Following Silastic Ring Vertical Banded Gastroplasty

Endoscopic Interventions and Jejunal Feeding in the Management of Acute Biliary Pancreatitis

Endoscopic Interventions and Jejunal Feeding in the Management of Acute Biliary Pancreatitis Tibor Gyokeres, Maria Burai, Eszter Schafer, Richard Schwab, Akos Pap Introduction: Acute biliary pancreatitis (ABP) is one of the most severe complications of the biliary stone disease. Its management is early endoscopic papillotomy followed by stone extraction if necessary, and conservative treatment of pancreatitis. Patients: During last four years we have treated twenty-nine patients (age: 21-92 years) with ABP, 17 of them had severe pancreatitis evaluated bymodified Imrie score. Twenty-six patients had stones in the gallbladder, twohad previous cholecystectomy and in one patient the gallbladder was stonefree. Methods: In case of suspected biliary origin of the pancreatitis we have performed duodenoscopy, endoscopic retrograde cholangiography and endoscopic papillotomy followed by stone extraction. At the end of the procedure we inserted feeding tube into the second loop of the jejunum. At the first day we have administered saline, on the second day diluted nutrient and from the third day to the healing we applied 1 ml/kcal nutrient in continuous infusion into the jejunum. Results: We performed 25 papillotomy, followed by stone extraction in 11 patients, and jejunal feeding was applied in 26 patients. The median time from the start of the symptoms to the interventionwas 1.5 (1-21) days. The hospital staywas 11 (2-81) days in average. One old patient died of pneumonia with healed pancreatitis and five died of complicated pancreatitis. All patient with fatal outcome had severe pancreatitis. Suprisingly not only the modified Imrie score, but the initial amylase value and the rate of the decrease had prognostic value: the higher initial amylase and the slow decrease was associated with poor outcome. In summary: Our results confirmed that acute biliary pancreatitis has a significant mortality even in case of proper timing of endoscopic papillotomy and with the best conservative treatment. *T1540 Endoscopic Treatment for Main Pancreatic Duct Rupture Following Silastic Ring Vertical Banded Gastroplasty Marianna Arvanitakis, Reza Chamlou, Myriam Delhaye, Celso Matos, Jean Closset, Jacques Deviere Background: Acute pancreatitis (AP) has been described as a rare complication of Silastic ring vertical banded gastroplasty (SRVG). It can be attributed to a pancreatic trauma occurring during surgery leading to segmental injury, AP and formation of pancreatic fluid collections (PFC). Endoscopic therapy is technically difficult in these patients, because of the presence of the small outlet channel formed by the ring, which limits the access to the distal part of the stomach and the transmural endoscopic approach of adjacent PFC. Patients and Methods: Four cases of patients having had SRVG (4 women, median age: 33 years (19-50)) for morbid obesity who presented post-operative AP, accompanied by main pancreatic duct disruption (MPDD) and PFC were managed endoscopically. Results: During a period of 16 months, out of 150 SRVG performed in our institution, AP associated with MPDD was recorded in 2 patients. Another two similar patients were referred fromother institutions. AP occurred at amedian of 4 (4-6) days after SRVG and MPDD (located at the body and tail junction) was documented 10 (6-35) days after SRVG by means of S-MRCP. Median interval between SRVG and endoscopic treatment was 15 (7-45) days. Indications for drainage were pain (n=2) and sepsis (n=2). All four patients had transmural drainage of PFC (median maximal diameter: 80mm (70-100)) under endoscopic guidance (n=4), associated with endoscopic ultrasonography (n=2) and/or fluoroscopic guidance (n=4) guidance, followed by the insertion of one or more plastic stents. Two patients had complementary transpapillary drainage including pancreatic sphincterotomy (n=2) and pancreatic stenting (n=1). Access to the distal gastric cavity through the outlet channel with the duodenoscope was technically difficult in all patients requiring the use of a guidewire, associated with pneumatic dilation up to 20 mm of the outlet channel in 2 patients and we performed a distal cystogastrostomy through the retroperitoneal cavity in one patient. Endoscopic therapy was successful in all patients, with subsequent resolution of PFC. One patient required drainage of a recurring collection 6 months following initial treatment. They are all asymptomatic with resolution of collections during a median follow up of 11 months (5-23). Conclusions: Endoscopic therapy is particularly useful in post SRVG AP with MPDD and, although technically difficult, should be considered as a first-line approach in the management of these patients.

The use of MRCP in the detection of pancreatic injuries after blunt trauma.

From January 2000 to November 2001, five consecutive, hemodynamically stable trauma patients (age range 8-69 years, mean age 34 years) with parenchymal injuries were evaluated by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). One patient also underwent a MRCP-facilitated secretin test. MRI depicted pancreatic laceration in two patients, ductal disruption and a post-traumatic intraparenchymal pseudocyst in one, migrating pancreatic fluid collection in the mediastinal space with disruption in another, and main pancreatic duct rupture and dilatation in the patient evaluated with MRCP following secretin administration. MRI with MRCP is an effective noninvasive test for detecting and managing pancreatic injuries after blunt trauma. Secretin administration improves ductal visualization, particularly of nondilated ducts. Finally, MRI was useful in the follow-up studies of parenchymal damage and minor ductal injuries, providing high-quality images of the pancreatic duct and biliary tract.

Indications for preoperative ERCP.

The indication for preoperative ERCP is about to be changed after the introduction of MRCP. There are however advantages of ERCP especially if the option of a therapeutic procedure, e.g., extraction of stones or placing of stents is considered. Besides ERCP prior laparoscopic cholecystectomy which is discussed elsewhere in this journal, indications for preoperative ERCP consist in patients after concussion trauma and hyperamylasemia as long as CT or MRI are not able to show pancreatic duct rupture. In this context the possibility of a stent placement is a major advantage of ERCP, since surgery may be avoided by this procedure. Preoperative ERCP may be performed in patients with chronic pancreatitis and refractory pain with the option of endoscopic therapy in cases with limited findings (less than 3 stones located in the pancreatic head). Furthermore, ERCP plays an important role in the preoperative differentiation between cystic neoplasms and pancreatic pseudocysts. Pseudocysts may be cured by endoscopical placement of transpapillary, transgastric or transduodenal stents. But so far no prospective studies have compared surgical with endoscopical drainage of pseudocysts. Finally, ERCP in the primary diagnosis of pancreatic carcinoma plays only a limited role and should be performed only if non-invasive methods are not able to clarify the situation.

Traumatic pancreatic duct rupture in a child, diagnosed by endoscopic retrograde pancreatography: K. Hirata, R. Ohta, Y. Tsurudome, et al. Eur J Pediatr Surg 7:48–49, (February), 1997

Traumatic pancreatic duct rupture in a child, diagnosed by endoscopic retrograde pancreatography: K. Hirata, R. Ohta, Y. Tsurudome, et al. Eur J Pediatr Surg 7:48–49, (February), 1997

Diagnostic and therapeutic ERCP in children: Safe with a high success rate in experienced hands

DIAGNOSTIC AND THERAPEUTIC ERCP IN CHILDREN: SAFE WITH A HIGH SUCCESS RATE IN EXPERIENCED HANDS Portwoed, A Maniatis, PS Jowell, MS Branch, J Affronti, S Guarisco, J Leung, PB Cotton, J Balliie, Division of Gastroenterology, Duke University Medical Center, Durham, NC Concern regarding the safety and success of diagnostic and therapeutic ERCP in children may limit the use of these potentially valuable interventions. Objective: To review the safety and success of diagnostic and therapeutic ERCP in children. Methods: A retrospective analysis of our database from 1988 1994. Results: 36 ERCPs were performed on 26 patients (13 male, 13 female) aged 3-18 years (median 13 years). 22 procedures were performed with general anesthesia and 14 with conscious sedation. A standard adult duodenoscope was used in all eases. Indications included recurrent idiopathic pancreatitis (8), eholedocholithiasis (7), trauma-related pancreatitis (6), suspected biliary leak (3), abdominal pain (3), gallstone pancreatitis (1), biliary obstruction without stones (1), and abnormal LFTs without pain (1). The common bile duct (CBD) and pancreatic duct (PD) were successfully cannulated in 31/31 (100%) attempts. Minor papilla cannulation was successful in 6/6 (100%) patients. One patient had an incomplete ERCP due to agitation under conscious sedation. Findings included pancreatitis without stones (5), PD cut off (5), biliary stones (4), biliary strictures (4), CBD abnormalities without stones/strictures (4), pancreas divisum (3), pancreatitis with stones (2), biliary leak (2), PD rupture (1), normal anatomical variant (1), and normal ERCP (5). There were 15 therapeutic interventions: sphincterotomy with stone extraction (2 CBD, 2 PD), stone extraction without sphincterotomy (3 CBD, 1 PD), stent insertion (3 biliary, 1 PD), biliary stricture dilatation (2), and nasobiliary drain placement (1). There were 4 immediate (but mild) complications: fever (2), rash (l), and mild pancreatitis (1). Conclusion: Diagnostic and therapeutic ERCP in children is well tolerated, safe and likely to be technically successful in experienced hands.

Endoscopic management of pancreatic disease

Since its introduction in 1968, ERCP has developed from being a purely diagnostic method, mostly used in the investigation of unexplained upper abdominal pain, to an invaluable tool for the management of patients with pancreatic disorders. In cases with severe gallstone pancreatitis, the biliary obstruction is disclosed and relieved by ERCP and ES. In patients with severe acute pancreatitis of other aetiologies, as well as in post-traumatic pancreatitis, ERCP is indispensable for revealing complications (e.g. pancreatic duct rupture) and/or for planning the treatment strategy. Furthermore, in cases of pancreatitis not related to alcohol or gallstones, it often demonstrates causes which may be treatable, and it is also useful for evaluation of the gland after massive pancreatic necrosis. Moreover, ERCP is helpful in establishing the diagnosis of chronic pancreatitis and its complications as well as in demonstrating morphological grounds for therapeutic intervention. Although the indications, limitations, and practicability of the different techniques of therapeutic ERCP in various pancreatic diseases still remain to be defined, the method appears to offer an alternative to surgery, particularly in cases in which operative treatment is technically difficult and the results are less favourable. Frequency and severity of complications associated with both diagnostic and therapeutic ERCP seem to be, at least in the hands of experts, reasonably low.

Pancreatic ascites: rupture of pancreatic duct in patient with chronic pancreatitis.

Pancreatic ascites: rupture of pancreatic duct in patient with chronic pancreatitis.