Non-operative management for pancreatic ascites: A case series

Pancreatic ascites (PA) is a rare entity which ers to the exudative fluid collection in the peritoneal cavity with elevated amylase levels secondary to either pseudocyst rupture or PD disruption. Pancreatic ascites commonly occurs in chronic pancreatitis, though it can also occur in acute pancreatitis. Other causes include tropical calcific pancreatitis, pancreatic trauma, biliary pancreatitis, etc. Due to its infrequent occurrence, the prevalence rate of PA is very low and it is more common in men.

The traditional conservative approach with nil by mouth, parenteral nutrition, somatostatin analogues and paracentesis is fraught with limited success. With the advent of magnetic resonance cholangiopancreatography (MRCP), PD disruption can be precisely located. As a result of this, early endoscopic interventions play a substantial role in non-operative management of PA. We hereby bring to the limelight three cases of PA complicating chronic pancreatitis managed by non-surgical approach.

Three young individuals with no previous history of ethanol abuse presented to our gastrointestinal (GI) surgical unit with similar history of dull aching recurrent abdominal pain, aggravated by food intake and relieved by analgesics along with progressive abdominal distension. Among this, one patient presented with recurrent episodes of vomiting and pain radiating to the back and one patient presented with diabetes mellitus. All three patients had frequent history of primary care hospital admissions and diagnosed to have chronic calcific pancreatitis and managed conservatively in the past (Table 1). No family history of pancreatitis.

All three patients underwent clinical examination (Table 2), laboratory investigations (Table 3), computed tomography (CT) abdomen scan (Figure 1). They were diagnosed to have PA complicating acute exacerbation of chronic calcific pancreatitis. After initial stabilization, all three underwent ultrasound guided PCD. In the initial weeks of PCD, patients had drain output of more than 1 L per day. All patients were managed conservatively with parenteral octreotide and total parenteral nutrition (TPN). They were gradually switched over to enteral feeds as tolerated. All patients showed symptomatic improvement with progressive decrease in abdominal distention.

Despite the improvement, two out of three patients had drain output more than 500 mL per day. Magnetic resonance cholangiopancreatography was taken after complete resolution of the ascites for these two cases (Figure 2). Both these patients showed proximal PD disruption (Figure 3). The other patient did not show any main pancreatic duct (MPD) abnormality on the MRCP. The first two patients were subjected to endoscopic transpapillary PD stent placement (Figure 4). Post-procedure PCD output started reducing from the first day and completely stopped within a week. Third patient was managed conservatively and after eight days of conservative management, PCD output started decreasing progressively (Table 4). All three patients had complete resolution of PA and got discharged after three weeks of admission with simple analgesics. None of them had recurrence of PA and on regular follow-up.

Pancreatic ascites is a rare entity complicating either acute or chronic pancreatitis. The first report of pancreatic ascites was published by Smith in 1953 which describes two cases of ascites with chronic pancreatitis [1]. Pancreatic ascites commonly occurs in the setting of chronic pancreatitis possibly as a result of ductal hypertension due to strictures and intraductal calculi. Pancreatic ascites in chronic pancreatitis is also ractory to the traditional conservative measures unless the ductal obstruction is relieved. Pancreatic ascites occurs secondary to either pseudocyst rupture or pancreatic duct dehiscence or both. Pancreatic ascites should be considered in any patient with chronic ascites and with history of chronic alcohol abuse, chronic pancreatitis, or abdominal trauma [2].

Our case series of three patients with pancreatic ascites in the setting of non-ethanol induced chronic pancreatitis is still rare. Chronic non-alcoholic pancreatitis can be idiopathic or due to tropical calcific pancreatitis (TCP) or fibrocalculous pancreatic diabetes (FCPD). Pancreatic ascites is differentiated from other causes of ascites like chronic liver disease or ascites due to tuberculosis by ascitic fluid amylase level of more than 1000 IU/L and a total protein of more than 3 g/dL [3],[4]. In our case series, diagnosis of PA is made with patient’s history, imaging evidence of ascites with altered pancreatic morphology and elevated amylase level in the ascitic fluid.

Management of patients with pancreatic ascites is challenging, as it is more common in the setting of chronic pancreatitis which per se causes nutritional depletion. The protein rich exudative ascites further leads to hypoproteinemia. The ascitic fluid further impairs the distensibility of the stomach leading to early satiety with consequent poor oral intake. In some cases with major pancreatic ductal disruption, the progressive and rapid accumulation of fluid leads to abdominal compartment syndrome with vital organ dysfunction [5],[6] especially in the acute pancreatitis setting.

An ultrasound abdomen is usually the first and basic investigation in such cases. A pancreas protocol multidetector CT of the abdomen can usually decipher the pancreatic pathomorphology with utmost precision. Magnetic resonance cholangiopancreatography is a valuable and viable tool in delineating the MPD morphology and site of ductal disruption, only after draining the ascitic fluid. A secretin stimulated MRCP increases the accuracy of detecting the site of ductal disruption, though not widely available. Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive investigation and can aggravate pancreatitis. It is usually used as a diagnostic cum therapeutic tool.

Treatment modalities for PA include conservative medical measures, endoscopic intervention, and if ractory, surgical management is opted. Conservative management constitutes nil per oral, TPN along with use of somatostatin analogues like octreotide is the initial step of management followed by image guided PCD placement to drain the ascitic fluid. Percutaneous catheter drainage placement is done with the premise that continuous drainage of the ascitic fluid leads to apposition of peritoneal surfaces with possible sealing of the disrupted PD site. Once the ascitic fluid is drained, an MRCP is done to delineate the ductal anatomy. In addition, endoscopic management like PD sphincterotomy and transpapillary PD stent placement has a definite positive result especially in patients with PA complicating chronic pancreatitis. Endoscopic retrograde cholangiopancreatography is also considered when there is a persistent or progressively increasing drain output and MRCP has failed to identify the site of MPD disruption. In our case series, one patient was managed conservatively with PCD alone and two patients were managed with both PCD and endoscopic PD stent.

Endoscopic retrograde cholangiopancreatography is an essential tool in the evaluation of patients with PA to locate the site of duct disruption and, subsequently, for placement of a transpapillary PD stent to bridge the fistulous area. Pancreatic fistulas are classified into three types, depending upon the anatomic position of the leak and PD anatomy. Type 1 pancreatic fistula indicates leakage from small side branches or from the distal end of the pancreatic duct. Type 2 pancreatic fistula ers to leakage from the main pancreatic duct. Type 3 leaks are post-surgical fistulas (occur after major surgical procedures like distal pancreatectomy or pancreaticoduodenectomy) [7]. Most of the pancreatic leaks can be managed by endoscopic interventional methods. During ERCP injection of contrast is kept to a minimum to reduce the risk of infection [8]. Other than pancreatic ascites, pancreatic duct stent placement is also helpful in pseudocyst and pancreaticopleural fistula with ductal communication [9].

ERCP has its own pros and cons. Proximal ductal disruptions can successfully be managed with a PD stent. The cons being the associated risk of aggravation of pancreatitis, inability to stent PD disruptions beyond a tight stricture or distal ductal disruptions. In addition there is always an associated risk of infection due to the procedure. In our series both cases had proximal ductal disruptions and were successfully stented.

Disconnected pancreatic duct syndrome (DPDS) is characterized by complete transection that results in a variable portion of the upstream pancreatic parenchyma becoming disconnected from the main pancreatic duct downstream [10]. This isolated segment of the pancreas will continue to produce its secretions leading to pancreatic ascites. The isolated portion of the pancreas cannot be reached from the papilla and theore the leak cannot be bridged endoscopically. Initially DPDS has required surgical management, but nowadays nonsurgical endoscopic alternatives are available [11],[12].

Endoscopic PD stenting offers an effective and safer first line therapy for patients with PA. The efficacy of the procedure persists after long-term follow up. Surgical intervention is necessary when medical and endotherapy fails. The surgery may become difficult in this condition due to the presence of pseudocyst or abscess and inflammation in the peripancreatic tissue [13]. Although few studies favor early surgical intervention with early recovery [14],[15],[16], this case series supports the existing data in four prior reported studies [1],[17],[18],[19]. Though endotherapy yields fruitful results, endotherapy and surgery are not mutually exclusive and complementary modalities.

In our case series, we have successfully managed PA with non-surgical measures which include PCD and endoscopic transpapillary PD stent placement. There was no recurrence of pain or PA at a mean follow-up of six months. Since this is a rare condition, randomized controlled studies to assess the superiority of endotherapy over surgery may not be practically feasible.

Image-guided PCD along with endoscopic PD stenting is a viable option in the management of PA complicating chronic pancreatitis in selected patients. Endotherapy effectively shortens the duration of the disease process and hence the morbidity in PA.