Acute Obstructive Suppuration of the Pancreatic Duct Causing Sepsis: 851

Purpose: Very few case reports of acute suppuration of the pancreatic duct (ASPD), an infectious process similar to ascending cholangitis have been described. In ASPD, pancreatic obstruction results in the development of infection, SIRS, and pus within the pancreatic duct (PD). Here we report of a case of ASPD successfully treated with emergent ERCP. A 33-year-old female with history of acute recurrent pancreatitis, likely secondary to tropical pancreatitis, presented with severe epigastric pain radiating to the back and nausea. She denied alcohol consumption, smoking, illicit, herbal, or prescription drug use. She reported multiple episodes of pancreatitis in the past and had previously undergone ERCP and cholecystectomy at an outside hospital. Ultrasound of the abdomen demonstrated CBD dilatation of 7 mm, consistent with post-cholecystectomy state. CT scan of the abdomen (PO and IV contrast) revealed acute pancreatitis, diffuse pancreatic atrophy, and ductal dilatation with obstruction due to a soft tissue lesion within the distal duct. Labs revealed normal pancreatic enzymes and an indirect hyperbilirubinemia (1.6/0.2). The patient was clinically stable upon admission and treated with bowel rest, pain management, and aggressive IV hydration. Within 24 hours she developed leukocytosis, hypotension, fever, and chills. Emergent ERCP was performed. The ampulla appeared edematous and a previous sphincterotomy was noted. The CBD was cannulated, “clean” bile emanated, and cholangiogram did not reveal biliary obstruction. After pancreatic ductal cannulation, copious pus emanated from the orifice. A pancreaticogram revealed diffuse PD dilatation and multiple filling defects, consistent with stones. A plastic single pigtail stent was placed traversing the ampulla and PD filling defects. Initially, pus drained from the stent, followed by clear pancreatic fluid. The patient rapidly improved over the following 24 hours. Prior to discharge, she underwent ERCP with pancreatic ductal sphincterotomy, stone extraction, and pancreaticogram, which revealed no further filling defects. ASPD is a rare and potentially fatal infectious complication of pancreatic ductal obstruction with few cases reported in the English literature. The paucity of this condition makes it an unusual diagnosis that should be considered in patients with AP who develop early clinical decompensation. As in this case, emergent ERCP and PD decompression is essential in the successful treatment of ASPD.Figure