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E2368. "Bridging the Gap": Etiology, Diagnosis, and Management of Pancreatic Ascites
Authors
  1. Brett Hausauer; Medical College of Georgia, Augusta University
  2. Matthew Potter; Medical College of Georgia, Augusta University
  3. Jayanth Keshavamurthy; Charlie Norwood VA Medical Center
Background
Pancreatic ascites is a rare cause of intra- and extraperitoneal fluid build-up, representing an estimated 1% of all cases of ascites, and is due to the leakage of enzymes from the pancreatic duct into the abdominal cavity via either an internal pancreatic fistula, a “disconnected duct,” or a “leaky” pseudocyst. These defects are, in turn, the result of underlying pancreatic pathology such as chronic necrotizing pancreatitis (most common), trauma, and malignancy. Underlying pancreatic pathology is a necessary but not a sufficient condition for the development of pancreatic ascites – that is to say, while all cases of pancreatic ascites imply a pancreatic abnormality, non-pancreatic ascites can also coincide with pancreatic pathology. As with other causes of ascites, patients with pancreatic ascites present with nonspecific symptoms including abdominal pain, distention, early satiety, or stigmata of infection/peritonitis. If ascites is visualized on ultrasound, CT, or MRI, the diagnosis is then clinched once peritoneal fluid is sampled; in pancreatic ascites, the fluid is exudative (serum-ascites albumin gradient (SAAG) < 1.1 g/dL) and exhibits increased fluid lipase levels (>1000 U/L). Additionally, a site of leakage (fistula or disconnected duct) is often – but not always - seen via ERCP or cross-sectional imaging (e.g. secretin-enhanced MRI). Once diagnosed, initial management is often conservative/medical with bowel rest (patient can be made NPO and given nutrition via parenteral or nasojejunal routes), medication (octreotide +/- somatostatin to reduce pancreatic enzyme secretion), and watchful waiting. In refractory cases, serial paracentesis, indwelling drains, pancreatic duct stenting, or (rarely) salvage surgery/necrosectomy can be performed, with endoscopic interventions offering overall better success rates and decreased mortality/morbidity. The purpose of this educational exhibit is to provide an overview of pancreatic ascites and its management, as illustrated by a case series of images from patients undergoing different treatment modalities.

Educational Goals / Teaching Points
- Provide an overview of the disease entity "pancreatic ascites" including its etiology, diagnosis, and management, as detailed above. - Specifically, that pancreatic ascites is diagnosed via direct fluid sampling demonstrating increased fluid amylase levels and a low SAAG. - Present images of patients diagnosed with pancreatic ascites, pre- and post-treatment (specific images of indwelling drains, pre- and post-paracentesis, and pancreatic duct stenting).

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
- Peritoneal fluid is visualized via US, MRI, or CT. - ERCP or secretin-enhanced MRCP may offer visualization of a pancreatic defect, but this is not critical for diagnosis. - Imaging may demonstrate other stigmata of chronic pancreatic disease, including pseudocysts, necrosis, pancreatic duct stenoses/fistulae/disruption, or calcifications.

Conclusion
Pancreatic ascites is a rare entity stemming from underlying pancreatic pathology which can be confidently diagnosed via fluid sampling and effectively treated using a variety of different modalities.