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ABSTRACTS: ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—BILIARY/PANCREAS: Presidential Poster Award

S1437 Acute Obstructive Suppurative Pancreatic Ductitis (AOSPD) as Initial Presentation for Pancreatic Adenocarcinoma

Sheikh, Taha MD1; Hamza bin Waqar, Syed MD2; Ghazaleh, Sami MD1; Burlen, Jordan MD1; Javaid, Toseef MD3; Nawras, Ali MD; FACG, 1

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The American Journal of Gastroenterology: October 2020 - Volume 115 - Issue - p S694
doi: 10.14309/01.ajg.0000707796.91293.5c
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INTRODUCTION:

AOSPD is a rare consequence of chronic pancreatitis characterized by acute infection of the pancreatic ducts while sparing pancreatic parenchyma. The distinguishing feature is lack of pseudocyst, abscess or necrosis formation. To date, only 20 cases are reported in literature. We describe a case of AOSPD precipitated by underlying pancreatic adenocarcinoma.

CASE DESCRIPTION/METHODS:

A 71-year-old female was admitted for confusion secondary to underlying UTI. Her medical history was significant for an alcohol use disorder and chronic pancreatitis. Urine cultures grew Klebsiella spp. while blood cultures were negative. Confusion and leukocytosis resolved with Ceftriaxone. However. 4 days later, she developed new onset dull epigastric pain. Labs were significant for AST 156, ALT 182, ALP 950, and GGT 2859 U/L. Total bilirubin and lipase levels were normal. Abdominal ultrasound showed a 14 mm stone in the pancreatic head with a dilated pancreatic duct (PD) and common bile duct (CBD) [Figure 1]. Abdominal CT scan revealed a 3cm obstructive mass in the pancreatic head with dilation of CBD and PD, measuring 16mm and 11mm respectively. ERCP showed high-grade distal CBD and PD stricture. Sphincterotomy followed by balloon dilation, yielded significant amount of pus, debris and stone fragments, requiring balloon catheter for further pus clearance. Brushing and biopsy of the PD and CBD stricture were taken, followed by stent placement in both ducts [Figure 2]. Patient's sepsis resolved after the pancreatobiliary drainage, consistent with the diagnosis of AOSPD [Figure 3]. Piperacillin-tazobactam was continued for ten days. Biopsy and brushings confirmed hepatobiliary primary invasive adenocarcinoma. Patient's family opted for hospice due to poor candidacy for aggressive therapy.

DISCUSSION:

AOSPD is an uncommon and potentially deadly complication of PD obstruction. Diagnosis and treatment is via ERCP by detection of purulent discharge from the PD and allowing adequate drainage. Rapid evaluation and assessment at a center with advanced endoscopy capabilities is essential. Broad spectrum antibiotic with anaerobic coverage given for 7-14 days compliments therapy. Patients presenting with AOSPD should be further evaluated for pancreatic malignancy as a potential complicating factor.

F1
Figure 1.:
Ultrasound abdomen ; A: 1.4 cm stone in pancreatic head with dilated ducts. B: Dilated Pancreatic duct of 1.1 cm within the pancreatic head. C: Common Bile Duct dilated at 1.1 cm.
F2
Figure 2.:
ERCP images : A: Balloon sweep of Pancreatic Duct with removal of pus, debris and sludge. B: Common Bile Duct and Pancreatic Duct stents at the end of ERCP.
F3
Figure 3.:
A-C: Trends in Transaminase, WBC and Total bilirubin during hospital stay.
© 2020 by The American College of Gastroenterology