S3230 Skin in the Game: Cutaneous Fistulization of Pancreatic Necrosis Presenting as Necrotizing Fasciitis

Introduction: Acute pancreatitis is an inflammatory condition characterized by abdominal pain and elevated serologic pancreatic enzyme levels with a reported annual incidence ranging from 4.9 to 35 per 100,000. Approximately 15-25% of patients will have necrotizing pancreatitis with necrosis of the pancreatic parenchyma, the peripancreatic tissue, or both. A recognized complication is fistulization of walled-off pancreatic necrosis (WOPN), typically occurring within within 3 months of index pancreatitis in 8-11% of necrotizing cases. These fistulae most commonly involve adjacent hollow viscera such as the stomach, duodenum, and colon. Case Description/Methods: We present the case of a 46-year-old woman with recent gallstone pancreatitis who presented to the emergency room with worsening diffuse abdominal pain. Computed tomography of the abdomen revealed diffuse peripancreatic collections with gas throughout the mesentery in the abdomen and pelvis, consistent with infected WOPN. She was started on antibiotics and ultimately underwent endoscopic ultrasound-guided cyst-gastrostomy with placement of a lumen-apposing stent which resulted in initial improvement in symptoms. However, on post-procedure day 2, she had recurrence of fevers and abrupt increase in white blood cell count from 24.2 to 39.2 K/µL. Examination revealed a distended abdomen, diffuse tenderness to palpation, and a well-demarcated, raised area of erythema on the inferior abdomen that was warm without exudate or discharge. Repeat computed tomography of the abdomen revealed interval worsening of the WOPN as well as gas deep to the left abdominal wall consistent with necrotizing fasciitis. She was taken emergently to the operating room for abdominal wall debridement and open pancreatic necrosectomy and was found to have a hole in the fascia and peritoneum communicating with the WOPN. Discussion: In this case, the nidus of abdominal wall infection was subcutaneous fistulization of the patient’s pancreatic necrosum. A review of the published medical literature revealed only 2 cases of complete cutaneous fistulization as a complication of attempted percutaneous drainage but did not identify any causing extensive soft tissue infection. Given that morbidity and mortality associated with open necrosectomy is reported to be around 30%, it is important for clinicians to have high index of suspicion for collateral infections related to pancreatic necrosis. This patient remains hospitalized for ongoing treatment of pancreatitis-related complications.