S3330 Management of Acute Obstructive Suppurative Pancreatic Ductitis: A Rare Clinical Entity With Serious Implications

Introduction: Acute obstructive suppurative pancreatic ductitis (AOSPD) can be defined as purulent drainage from the pancreatic duct, leading to infection. While rare, it is important to distinguish it from cholangitis, other pancreatic pathologies, and other causes of sepsis. Here, we present the case of sepsis due to AOSPD managed endoscopically. Case Description/Methods: We present the case of a 54-year-old woman with a history of spontaneous splenic rupture status post splenectomy and recurrent acute on chronic pancreatitis with multiple outside endoscopic retrograde cholangiopancreatography (ERCP)s, who presented with 1 day of nausea, vomiting, inability to tolerate PO intake, and abdominal pain. She became febrile during admission to 101.3 F. On physical examination, she had mild epigastric tenderness. Her lab work revealed a leukocytosis of 34.3, lactic acid of 1.7, AST of 20, ALT of 22, ALP of 132, a total bilirubin of 0.6, and a lipase of 1149. She underwent computed tomography abdomen pelvis with intravenous contrast that showed a dilated pancreatic duct with multiple calcified stones within the pancreatic duct and intraparenchymal pancreatic calcifications. An ERCP was performed with cannulation of the ventral pancreatic duct. Pancreatography revealed a diffusely dilatated pancreatic duct to 20 mm with intraductal stones. Balloon sweeps of the ventral pancreatic duct yielded white stone debris and purulent material. A 7 Fr × 12 cm pancreatic duct stent was placed which continued to drain purulent material. Given the endoscopic findings a diagnosis of acute obstructive suppurative pancreatic ductitis was made. Her symptoms and sepsis improved promptly, and she was discharged from the hospital with antibiotics to finish a 10-day course. She was planned for a repeat ERCP in 6 weeks for pancreatoscopy and lithotripsy with stent exchange. Discussion: The differential diagnosis for a patient with a history of chronic pancreatitis who presents with fever and abdominal pain is broad. While acute-on-chronic pancreatitis and cholangitis are more common diagnoses, it is important to consider AOSPD as a cause of abdominal pain and sepsis. Awareness of the entity of AOSPD can help expedite appropriate interventions which can greatly impact the outcome for patients.