LETTER TO EDITOR

JOP. J Pancreas (Online) 2014 Nov 28; 15(6):628-629.

Spontaneous Intra-Gastric Walled-Off Pancreatic Necrosis Rupture

Nikolaos Papadimitriou¹, John Robotis², Theodoros Rokkas²

¹Department of Gastroenterology, Metropolitan General Hospital; ²Henry Dunant General Hospital. Athens, Greece

Dear Sir,

A seventy two-years old male presented with fever, abdominal discomfort and vomiting six weeks after an episode of gall stone acute pancreatitis. An i.v. contrast abdominal Ct scan revealed a cystic collection 6x7 cm with air level at the tail of pancreas bulging towards stomach. Lab exams revealed only leukocytosis. On gastroscopy a small fistulous opening was found at the posterior wall of upper stomach corpus. A pus like discharge from the opening was noted (Figure 1). Further, the fistulous opening was step-wise dilated so that the instrument tip carefully entered the cavity (Figure 2). The cavity was full of debris, semi-solid necrotic material and a greenish liquid. Culture sample and cytology were both negative. The debris was aspirated through the scope meticulously. Further, the cavity was thoroughly irrigated with sterile normal saline and a nasobiliary catheter was left inside to secure a continuous irrigation along with drainage. The patient was kept on nil by mouth, i.v. broad spectrum antibiotics and gradually recovered uneventfully. White blood cells returned to normal and an i.v. contrast CT scan two months later depicted no fluid collections.

Figure 1. Intra-gastric fistula with pus exudate.

Figure 2. Walled-off pancreatic necrosis interior.

Fortunately, the spontaneous rupture of this walled-off pancreatic necrosis in the stomach of our patient was both uneventful and therapeutic. Additional manipulations with suction and intra-cystic irrigation further contributed to our patient clinical improvement.

Walled-off pancreatic necrosis (WOPN) is a serious complication that may ensue at least four weeks after an episode of acute pancreatitis. According to the revised Atlanta Classification, fluid collections that appear in the setting of pancreatic necrosis are further categorized as acute necrotic collections (ANC) or progressively to WOPN based on their maturity. Additionally, the revised Atlanta classification recommends that the presence of any solid material or debris in pancreatic collections named as WOPN [1]. CT scan presents a moderate discriminate cut-off, only 45% to identify solid debris in WOPN [2]. The incidence of acute pancreatic fluid collections, in general, varies from 30 % to 50 % and most of them resolve spontaneously [3]. It is only symptoms or complications that necessitate intervention and not the size [3]. Cysts larger than 6 cm, protruding stomach wall can endoscopically be treated via cyst gastrostomy [4]. Endoscopic ultrasound, if available, can safely delineate confounding vasculature prior to any endoscopic intervention. The natural history of WOPN without any intervention is unknown. Spontaneous uncomplicated rupture of WOPN into stomach is very rare, less than 3% [5]. This favorable outcome is considered the rationale for endoscopic drainage of walled -off pancreatic fluid collections.

Received September 16th, 2014 – Accepted September 23rd, 2014

Key words Gastroscopy; Pancreatic Juice; Rupture, Spontaneous

Abbreviations WOPN: walled-off pancreatic necrosis

Conflict of interest Authors declare to have no conflict of interest

Correspondence
John Robotis
108 Ifigeneias Street
176 76, Athens
Greece
Phone: +30-697.715.2485
E-mail: jfrobotis@yahoo.com

References

1. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013: 62; 102-111.

2. Takahasi N, Papachristou GI, Schmit GD, et al. CT findings of walled-off pancreatic necrosis (WOPN) differentiation from pseudocyst and prediction of outcome after endoscopic therapy. Eur Radiol 2008: 18; 2522-2529. [PMID: 18563416]

3. Tenner S, Steinberg W. Acute pancreatitis. In Sleisenger and Fordtrans, Gastrointestinal and Liver Disease, 9th edition, Saunders 2010; 980-982.

4. Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts and chronic pancreatic pseudocysts. Gastrointest Endoscopy 2002; 56:7-17. [PMID: 12085029]

5. Mir MF, Shaheen F, Gojwari TA, Singh M, Nazir P, Ahmad S. Uncomplicated spontaneous rupture of the pancreatic pseudocyst into the gut-CT documentation: a series of two cases. Saudi J Gastroenterol 2009; 15: 135–136. [PMC: 2702964]