S5256 Multifocal Pancreatic Pseudocysts With Multifocal Pancreatic Duct Leak: A Role for Transpapillary Drainage

Introduction: Pancreatic pseudocysts are a known complication of pancreatitis. In rare cases, persistent or recurrent fluid collections may result from pancreatic duct (PD) disruption with leaks. This case highlights multifocal pseudocysts with suspected multifocal PD leak in a transgender man with alcohol-associated pancreatitis, leading to pancreatic ascites, bacterial peritonitis, and inferior vena cava (IVC) compression. Case Description: A 37-year-old transgender man with alcohol use disorder presented with epigastric pain. Computed tomography (CT) imaging revealed acute-on-chronic pancreatitis with large pseudocysts causing mass effect on the portal-splenic confluence and biliary ductal narrowing, with small-volume ascites. He was initially managed conservatively, but symptoms persisted with worsening collections, ascites, and signs of secondary bacterial peritonitis. Paracentesis confirmed pancreatic ascites (elevated lipase, low serum-ascites albumin gradient with neutrophilic leukocytosis and growth of Streptococcus mitis. Endoscopic ultrasound identified 2 large pseudocysts; a 5.5 cm × 5 cm cyst near the antrum was drained using a lumen-apposing metal stent (LAMS). A second 5.5 cm cyst compressing the intrahepatic IVC was aspirated via fine needle aspiration but reaccumulated after 2 days. Due to incomplete resolution of cysts, endoscopic retrograde pancreatography (ERP) was performed and revealed PD leaks near the neck of the pancreas. A 5 Fr × 5 cm PD stent was subsequently placed. Despite initial improvement in ascites, the collections worsened. Repeat ERP showed contrast pooling into a large cyst and gastric opacification, suggesting a fistula from prior cystgastrostomy to the PD and persistent leak into an upstream cyst. A longer 7 Fr × 15 cm double-pigtail stent was placed into the pseudocyst to enable transpapillary drainage, bridging multiple leak sites. A CT at 3 months showed complete resolution. Discussion: While LAMS is effective for individual collections, transpapillary drainage should be considered for persistent or recurrent multifocal fluid collections unresponsive to standard drainage. There is limited data to support a combined transmural-transpapillary approach, but it may be useful for large upstream pseudocysts and downstream PD leaks, allowing both cyst drainage and ductal bridging.