Pancreatic Ascites

Pancreatic ascites is accumulation of pancreatic fluid in the peritoneal cavity from disruption of the main pancreatic duct or a leaking pseudocyst.

• Accounts for under 3% of ascites, and 3 to 7% of chronic pancreatitis patients.
• Causes: chronic pancreatitis (alcohol, 70 to 90%), acute pancreatitis, trauma, surgery, pseudocyst rupture, malignancy.
• Mechanism: ductal disruption with posterior leak into the retroperitoneum and then peritoneum (ascites) or into the pleural space (pancreatic pleural effusion).
• Complications: malnutrition, secondary infection, respiratory compromise, recurrence.

• Abdominal distension, mild pain, weight loss, nausea, dyspnoea (with pleural effusion).
• History of chronic alcohol use and pancreatitis.
• Ascites with minimal inflammatory signs, may be refractory to diuretics.
• Pleural effusion (left sided) in 30%.

• Diagnostic paracentesis: high amylase (over 1000 U/L, often over 5000), protein over 3 g/dL (exudate), SAAG under 1.1 g/dL, low white count (lymphocytes), negative culture and cytology.
• Serum amylase and lipase, albumin.
• Imaging: CT (pancreatic calcification, duct dilatation, pseudocyst, ascites), MRCP (ductal disruption, leak), secretin enhanced MRCP.
• ERCP localises the leak (extravasation of contrast) and enables treatment.
• Exclude malignant, tuberculous or cirrhotic ascites.

• Conservative therapy for 2 to 3 weeks: serial paracentesis, nil by mouth with parenteral nutrition or nasojejunal enteral feeding, octreotide 100 to 250 micrograms SC three times daily (reduces pancreatic secretion), diuretics (limited value).
• Success of medical therapy about 50 to 60%.
• Endoscopic therapy for failure or sooner: ERCP with transpapillary pancreatic duct stent bridging the leak (5 to 10 Fr, 6 to 12 weeks), plus sphincterotomy; success 60 to 80%. Prophylaxis against post ERCP pancreatitis (rectal indomethacin 100 mg).
• Surgery for failed endoscopic therapy: pancreaticojejunostomy (Roux-en-Y) to the leak site, or distal pancreatectomy for tail disruption; success over 90%.
• Pseudocyst related leak: treat as pseudocyst.
• Nutritional rehabilitation, alcohol abstinence, pancreatic enzyme replacement.
• Antibiotics for infection (piperacillin tazobactam 4.5 g every 6 hours).
• Follow up for recurrence, with repeat imaging.