A Case of Severe Acute Gallstone Pancreatitis With Black Ascites in a Patient Without Underlying Diseases

In acute pancreatitis, ascitic fluid is typically pale yellow and exudative due to inflammation. We report a rare case of black ascitic fluid associated with gallstone-induced severe acute pancreatitis in a 71-year-old man with no underlying disease. The patient initially presented to a local hospital with acute-onset abdominal pain. Abdominal computed tomography (CT) revealed a common bile duct stone, and he was diagnosed with acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and endoscopic nasobiliary drainage (ENBD) was performed. On the following day, his abdominal pain worsened, and further evaluation revealed elevated pancreatic enzyme levels and peripancreatic inflammatory changes on CT. He was subsequently diagnosed with acute pancreatitis. Despite four days of treatment with fluid resuscitation and antibiotics, his condition deteriorated, and he was transferred to our facility on Day 0. Upon arrival, he was intubated and started on mechanical ventilation due to respiratory failure. Continuous hemodiafiltration (CHDF) was initiated on Day 1 for metabolic acidosis and worsening renal function. On Day 3, abdominal CT revealed newly developed ascites, and paracentesis was performed due to concern for increased intra-abdominal pressure. The ascitic fluid appeared black. Laboratory analysis revealed a mildly elevated total bilirubin level and markedly elevated amylase and lipase levels, consistent with pancreatic ascites. Despite drainage and intensive supportive care, the patient developed multiple organ dysfunction syndrome (MODS), including refractory shock, respiratory failure, and renal insufficiency. He died on Day 5 of hospitalization. This case highlights an extremely rare presentation of pancreatic ascites with black discoloration in the early phase of acute pancreatitis. The black color was most likely due to pancreatic duct disruption and enzyme-mediated hemorrhagic changes. To our knowledge, this is the first reported case of black pancreatic ascites secondary to acute pancreatitis. Awareness of this rare manifestation may aid in the timely recognition and management of similar cases in the future.