EUS Guided Drainage of Hemorrhagic Pancreatic Fluid Collection We have no disclosures. Hemorrhagic pancreatic fluid collection is a rare and serious complication of acute and chronic pancreatitis resulting from bleeding pseudoaneurysm, small vessel hemorrhage, or venous bleeding. These collections have traditionally been managed with percutaneous angiographic embolization of the bleeding vessel and or surgery. There are few case reports available in the literature highlighting the safety and efficacy of endoscopic management in such patients. A 63-year-old male presented to the GI clinic with complaints of postprandial epigastric pain, bloating, and early satiety. His past medical history was significant for type 2 diabetes, hypertension, and recurrent episodes of acute pancreatitis secondary to alcohol abuse, with his last episode occurring two months prior to presentation. Routine lab workup, including CBC, LFTs, and lipase, was normal. CT Pancreas Protocol demonstrated a large fluid collection measuring 11.3 x 14.9 cm in size. Numerous prominent perisplenic and perigastric collaterals were present. High attenuating fluid with hyperdense contents was seen within the collection, suggestive of intracystic bleeding. The collection resulted in significant mass effect on the stomach. The patient was diagnosed with hemorrhagic pancreatic fluid collection and underwent CT angiography. There were no vascular abnormalities noted in the splenic, left gastric, common hepatic, and gastrodurinal arteries. After discussion with the patient, the decision was made to proceed with EUS-guided transmural drainage. Using a linear echo endoscope, a large pancreatic fluid collection was visualized adjacent to the gastric wall. Echogenic contents, suggestive of blood, was seen within the collection. FNA using a 19-gauge needle revealed hemorrhagic fluid. Endoscopic transmural drainage was performed using a 15mm x 10mm lumen-opposing metal stent. The proximal flange of lambs was deployed under EUS guidance. Following deployment of the distal flange, blood-tinged fluid could be seen draining from the cyst cavity into the stomach. The echo endoscope was exchanged with a foreviewing endoscope, and balloon dilation of the stent was performed to 15mm. This was done under endoscopic and fluoroscopic guidance. Once this was complete, the lambs was traversed with the endoscope to visualize the hemorrhagic collection. Copious amounts of blood clots with scant necrotic material were seen inside the cyst cavity. There was no active bleeding noted. The cavity was lavaged with 300ml of normal saline to dislodge the clots adherent to the cyst wall. Following this, a polypectomy snare was advanced into the collection and blood clots were carefully removed under direct visualization. Due to extensive clot burden, the same maneuver was repeated multiple times to achieve adequate clearance. Post-procedure MRCP showed a decrease in size of the PFC. Of note, there was complete disruption of the main pancreatic duct with viable pancreatic tissue seen in the head and tail of the pancreas. The above findings were suggestive of disconnected pancreatic duct syndrome. Repeat CBC done post-procedure showed a stable hemoglobin. The patient was discharged home the following day without any complications. Endoscopy at 2 weeks showed a healthy appearing cyst wall with no residual blood clots. The lumen opposing metal stent was removed using a rat tooth forceps and two 10 French by 4 cm double pigtail plastic stents were placed in the cyst cavity for long term drainage. The patient was scanned at 4 week follow up with near complete resolution of his PFC. He was asymptomatic and will be seen in 3 months with follow up imaging. U.S. guided transmural drainage provides a safe alternative to surgery in patients with hemorrhagic PFCs. Prior to endoscopic drainage, CTA should be performed in all patients for identification and embolization of any bleeding pseudoaneurysms. Long term transmural drainage with double pigtail plastic stents improves recurrence free survival in patients with disconnected pancreatic duct syndrome. www.ottobock.com

endoscopic ultrasound guided drainage

hemorrhagic pancreatic fluid collection

acute pancreatitis

chronic pancreatitis

endoscopic management