Daniel Cole, M.D., M.P.H.
Pancreatic ascites is an uncommon cause of ascites, accounting for about 1% of all cases. It presents with some unique issues of evaluation and treatment when this diagnosis is suspected.
The patient is a 49-year-old male presenting with a combination of abdominal pain, nausea, vomiting and increasing abdominal girth. He came to the Emergency Department because he could no longer care for himself. He has a very long history of alcohol abuse. He drinks more than a fifth of vodka per day. He cures his tremors with more alcohol. His abdomen has been increasing in size over the preceding 3 weeks; at the time of presentation, it had gotten so large that he could barely stand and could not eat.
He denied any prior hospitalizations for alcohol problems. He denied any history of liver disease or pancreatic disease. He smoked 1.5 packs per day. Physical examination on admis-sion revealed a well-developed but very disheveled male complaining of abdominal pain. He had multiple excoriations from scabies. With the excep-tion of the abdomen, the remainder of the physical exam-ination was normal. The abdomen was markedly distended with obvious massive ascites. The liver and spleen were not palpable. There was diffuse tenderness but not rebound or guarding. The lab on admission showed a hemo-globin of 10.5, white blood cell count 9,900, aspartate amino-transferase 69, alkaline phos-phatase 354, bilirubin 0.6, amylase 269 and lipase 387. The ascitic fluid was tapped, showing an albumin of 1.5, protein 3.3, white blood cell count 1090 with 41% polycytes and 52% monocytes. The amylase was 3700. During his hospitalization, several computed tomographic (CT) scans were done, demonstrating enlarging pancreatic pseudocysts (Figure 1). Endoscopic retrograde cholangiopancre-atography (ERCP) failed to localize any specific site of leak from the pancreatic duct.
Pancreatic ascites is defined as massive accumulation of pancreatic fluid in the peritoneal cavity.1 The amylase is generally above 1,000 and often in the 5,000 to 10,000 range. It can be due to traumatic rupture of pancreatic duct from recent abdominal trauma such as a car steering wheel injury, or more likely from chronic alcoholic pancreatitis.2 It has been described in approximately 4% of patients with chronic pancreatitis and in 6% to 14% of those with pancreatic pseudocysts.3 Many patients with alco-holic pancreatitis may not even have abdominal pain and therefore it might be confused with ascites from cirrhosis. The confusion is less likely when there is a history of recent trauma. As with any cause of ascites, paracentesis is mandatory. Treatment of ascites is dependent on the etiology and the best way to deter-mine this is with paracentesis. In the case of pancre-atic ascites, in addition to an elevated amylase, it is usually an exudate with the serum albumin ascites-gradient less than 1.1 grams/dl.
Once the diagnosis is confirmed, most experts recommend a conservative approach since about one-third of cases will resolve spontaneously.4 Generally, ERCP is not recommended in patients with pseudo-cysts since there is a risk of converting the pseudocyst to an abscess. However, in the case of pancreatic ascites with a pseudocyst seen on CT scan, an ERCP is recommended to try to localize the site of the leak. This is helpful in case surgery becomes necessary since the location of the leak determines the extent of surgery. In several studies, octreotide or somatostatin has been shown to assist in healing, presumably by decreasing pancreatic output.5 Stenting during ERCP has also been effective in allowing the tear to heal.
Ultimately, though, two-thirds of patients will need surgery.6 As indicated previously, the type of surgery is dependent on the location of the leak. A distal duct leak can be dealt with by distal pancreatectomy. If the leak is from a pseudocyst, then internal drainage may be sufficient. This can often be done via endoscopy rather than open surgery. If necessary, a partial pancreatic resection can be combined with a Roux-en-Y loop to drain the duct.7
Submitted August 26, 2006