S3523 Hepatic Steatosis and Hemorrhagic Pancreatitis: A Deadly Duo

Introduction: Pancreatitis may cause disruption of pancreatic microcirculation in its severe forms. This leads to development of hemorrhagic pancreatitis(HP),a rare complication with incidence between 1%-23% and fatality rates approaching 50%. Case Description/Methods: A 43-year-old woman with a history of Alcohol use disorder presented with abdominal pain and vomiting of unclear duration. Labs revealed elevated White blood cell count (WBC), elevated INR, Acute kidney injury (AKI) and lactic acidosis. Computed tomography of the chest, abdomen and pelvis(CAP) showed hepatic steatosis but no acute findings. She was intubated, aggressively resuscitated with fluids and given broad-spectrum antibiotics. Diagnostic laparoscopy was positive only for severe hepatic steatosis. Testing for Serum Volatiles was negative and her acidosis improved with fluid resuscitation. She remained intubated and her AKI progressed, requiring Hemodialysis. Nine days later she developed a rise in WBC with intermittent fevers. Infectious work up was unremarkable. Computed tomography CAP showed an enlarged pancreas with fat stranding near the tail and fluid in the left pericolic gutter concerning for acute pancreatitis. The next day she became hemodynamically unstable and repeat Hemoglobin (Hgb) was 3.2 g/dl. Computed tomography Angiogram CAP revealed a new 19 cm hematoma within the abdomen. She underwent emergent exploratory laparotomy where a large hematoma at the greater curvature of the stomach and transverse colon mesentery with pancreatic capillary bleeding, saponification and necrosis were noted. Discussion: HP is due to bleeding from pseudoaneurysms, pseudocysts, pancreatic necrosis or due to trauma. It Is more common in middle aged adults with chronic heavy alcohol use. Fatty Liver has also been recognized as a risk factor for pancreatitis and is associated with more severe forms of the disease, local complications and organ failure leading to death. Fatty infiltration of the pancreas itself disrupts tissue function. Future imaging techniques may help measure fat deposits and aid with risk stratification so that appropriate resuscitation efforts take place. Careful monitoring of Hgb, electrolytes and hemodynamic status in these patients may help with early detection. Computed tomography or magnetic resonance imaging are helpful in identifying the etiology for bleeding but exploratory laparotomy is the gold standard for diagnosing and helping to control bleeding. Endovascular techniques are appropriate treatment options for patients who are hemodynamically stable or with smaller pseudoaneurysms.