S3228 Liver Is Not Always the Culprit: A Rare Case of Pancreatic Ascites

Introduction: Pancreatic ascites is defined as intraperitoneal fluid collection secondary to recurrent pancreatic duct leakage or rupture of pancreatic pseudocyst. Due to the weaker wall of the pseudocyst, leakage of pancreatic secretions into the peritoneum occurs through disrupted ducts causing ascites. Given the rarity of this entity, only approximate prevalence is known from the available data, which is around 3.5% amongst all cases of chronic pancreatitis. Case Description/Methods: A 68-year-old man with past medical history significant for pancreatic pseudocyst, chronic pancreatitis along with alcohol use disorder and questionable history of cirrhosis presented to the hospital with complaints of numerous episodes of coffee-ground emesis. The physical exam was remarkable for severe malnutrition and a distended abdomen which was tender and dull to percussion. The patient underwent diagnostic and therapeutic paracentesis. Serum-ascitic albumin gradient (SAAG) score was <0.5. Computed tomography of the abdomen pelvis did not show any evidence of cirrhosis. Pancreatic fluid studies revealed amylase of 112. It was noted that patient had a history of recurrent high volume ascites requiring paracentesis. Given his significant history of alcohol use, it was presumed in the past encounters that his ascites was cirrhotic in nature. However, given no cirrhosis on imaging and preserved synthetic function of liver on labs, there was concern for rare but possible cause of ascites- pancreatic ascites. Labs from the past revealed amylase levels as high as 13,890 a month ago, further supporting our diagnosis of pancreatic ascites. Discussion: Pancreatic ascites can be diagnosed by ascitic fluid analysis. Fluid studies typically reveal amylase >1000 IU/L, total protein >3 gm/dL, and SAAG <1.1 gm/dL. This helps us to differentiate from ascites due to portal hypertension or other causes like tuberculosis and malignancy. It is important to know exact etiology of ascites as treatment differs markedly and affects overall prognosis. Pancreatic ascites is a rare but known complication of chronic pancreatitis. Its diagnosis can be challenging, however, detailed history and physical exam along with fluid analysis can help in timely diagnosis and treatment. This case underscores the importance of having a broader differential when dealing with patients with ascites of unknown etiology and how history of alcohol use can lead to anchoring bias ultimately delaying our diagnosis.