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Ascites is an uncommon presentation after pancreatitis. The usual causes include pancreatic duct leaks, portal vein thrombosis, and overly aggressive fluid resuscitation in the acute setting of pancreatitis.
We describe the case of a 67-year-old woman with a history of severe acute necrotizing pancreatitis 5 years previously, complicated by walled-off necrosis that required percutaneous and transgastric drainage. She finally recovered after a long hospitalization. She had been doing well for the years since her hospitalization until recently, when she experienced rapidly progressing abdominal distention. On physical examination, she was found to have tense ascites. A paracentesis showed straw-colored fluid with a serum ascites albumin gradient of over 1.1 and a very low amylase level. She had no history of liver disease. Abdominal imaging showed a 5 × 7 cm pancreatic fluid collection (PFC) that was causing severe compression of the portal vein (Figs. 1A and B).
Figure 1A, CT view of abdomen showing pancreatic fluid collection compressing the portal vein before entering the liver (arrow). Severe ascites is also visible. B, View of patient’s abdomen showing the severity of her ascites before the procedure. C, Control CT view of abdomen after procedure, showing resolution of PFC and visualization of lumen-apposing metal stent (LAMS). The portal vein is seen and is widely patent. No ascites is visualized. D, View of patient’s abdomen after procedure, showing complete resolution of ascites. LAMS, lumen-apposing metal stent.
We performed EUS-guided drainage of the PFC using a cautery-enhanced lumen-apposing metal stent (LAMS) (Video 1, available online at www.VideoGIE.org). After 4 weeks, her ascites completely resolved, and abdominal imaging showed that the portal vein was widely patent (Figs. 1C and D). We removed the LAMS endoscopically 6 weeks after the procedure, and the patient continues to do well.
Most PFCs are indolent. The indications for drainage include symptoms, infection, or both. EUS-guided drainage was initially performed by the placement of multiple plastic stents; however, LAMSs were developed specifically for PFC drainage. Recent studies have shown that these stents can be placed safely and effectively, with resolution rates of over 90%.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Endoscopic pancreatic fluid collection drainage using a lumen-apposing metal stent in a patient with severe ascites caused by a pancreatic fluid collection that compressed the portal vein.
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