S3358 Rapid-Onset Necrotizing Pancreatitis With Multivessel Thrombosis in a Young Alcohol User

Introduction: Alcohol-related pancreatitis can range from mild to life-threatening, but rapid evolution to necrosis with extensive abdominal vessel thrombosis is rarely seen, especially within the first 48 hours. We present a rare case of a young adult who developed early pancreatic necrosis with multi-vessel thrombosis in the absence of prior pancreatitis. Case Description/Methods: A 32-year-old man with heavy daily alcohol use and concurrent tobacco and cannabis use presented with acute-onset epigastric pain, nausea, and vomiting. Initial labs showed elevated lipase (1211 U/L), transaminitis, hyperbilirubinemia, hyponatremia, and elevated lactate. Computed tomography imaging confirmed interstitial pancreatitis without necrosis. He was managed conservatively with bowel rest, intravenous fluids, and analgesia. By hospital day 2, he developed tachycardia, low-grade fever, and worsening abdominal tenderness. Repeat imaging revealed pancreatic necrosis involving the body, tail, and uncinate process. There was also splenic vein occlusion, partial thrombosis of the superior mesenteric vein, and narrowing of the hepatic artery. Free fluid and pleural effusions were noted. Anti-coagulation with heparin was initiated, and he was transferred for advanced care and potential intervention. Discussion: This case reflects an uncommon and aggressive progression of pancreatitis, with necrosis and early involvement of multiple vascular structures. Although splenic vein thrombosis is a recognized complication, concurrent compromise of the superior mesenteric vein and hepatic artery in the acute phase is highly atypical. The combination of alcohol-induced endothelial injury, hemoconcentration, and systemic inflammation may have contributed to this rapid vascular compromise. Anticoagulation in pancreatitis-related thrombosis is controversial, often weighed against bleeding risk. However, in the absence of hemorrhage or pseudoaneurysm, early initiation may help preserve organ perfusion and limit propagation. This case also emphasizes the need for serial imaging in patients with rapid clinical decline, as vascular events can develop early and silently. Timely recognition and a coordinated multidisciplinary approach—including gastroenterology, surgery, radiology and critical care—are essential in guiding therapy and optimizing outcomes in such high-risk scenarios.