Title

Pancreatic Panniculitis: A Harbinger of Systemic Inflammatory Response Syndrome From Spontaneous Rupture of Massive Pancreatic Pseudocyst

Document Type

Poster Presentation - Tower Health Access Only

Publication Date

10-9-2018

Abstract

Abstract Body: Introduction: Pancreatic panniculitis (PP) is an uncommon manifestation of pancreatic diseases. PP in association with spontaneous rupture of a pancreatic pseudocyst has been rarely reported in the literature.

Case: A 34-year-old female with history of acute alcoholic pancreatitis presented to the ED with abdominal pain, nausea and vomiting. She reported alcohol use a few days prior to the onset of symptoms. Lipase was 2,040 IU/L (normal 11-82 IU/L). CT of the abdomen/pelvis showed peripancreatic fat stranding and fluid, consistent with acute pancreatitis, and a few cystic structures adjacent to the pancreas believed to be developing pseudocysts. Her symptoms improved slowly with conservative management and she was discharged on day 6. A week later, she returned to ED with recurrent pain, nausea, vomiting, and new erythematous tender nodules on lower extremities (Figure 1A). CT abdomen/pelvis now revealed a new massive pseudocyst within the left side of the abdomen, anterior to the body and tail of the pancreas, measuring 20 x 12 x 15 cm (Figure 2). During CT-guided drainage of the pseudocyst, it was discovered that the pseudocyst had already spontaneously ruptured into the peritoneum. Trans-gastric drainage of the residual pseudocyst was unsuccessful; 1659 cc of ascites was drained. Following the procedure, she developed worsening pain, tachycardia and leukocytosis. She had emergent diagnostic laparoscopy, irrigation and lavage of abdomen, and placement of abdominal drains. She was discharged 8 days post-operatively. Three days later, she was re-hospitalized for recurrent gastrointestinal symptoms. The painful skin nodules had progressed to the upper extremities (Figure 1B). CT abdomen/pelvis now revealed hemorrhagic transformation of the remaining cyst and necrotic changes in the pancreatic head. After stabilization, she underwent skin biopsy which showed dense inflammation with many neutrophils and necrosis, consistent with PP (Figure 3). Her symptoms improved slowly over 2 weeks with conservative management and she was discharged home with subsequent resolution of her skin lesions a week later.

Discussion: PP is an uncommon necrosis of subcutaneous fat that, may be a harbinger of an underlying pancreatic disorder (including pancreatitis, cancer and pseudocyst). Prompt recognition and appropriate management, by addressing the underlying pancreatic disease, may allow for earlier treatment that could improve clinical outcomes.

Publication Title

American College of Gastroenterology Annual Meeting

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