What is Pancreatic Ascites?
Pancreatic ascites is a medical condition where fluid from the pancreas accumulates in the abdomen. This mainly happens due to continuous leakage from the pancreatic duct or when a pancreatic pseudocyst, a kind of fluid-filled sac, ruptures into the abdomen. This condition is often linked with chronic pancreatitis typically caused by excessive alcohol consumption.
Other less common reasons for pancreatic ascites include biliary pancreatitis, trauma to the major pancreatic duct, narrowing of the ampulla of Vater (a small opening that drains pancreatic and bile fluids), duplication of the cystic duct, and gallstone disease. The seriousness of this condition can vary greatly. It mainly depends on where and how severe the ductal injury is, and whether an infection is present. Mild cases can resolve on their own, but if it’s infected or continuous, or if it’s associated with pancreatic duct cancer, it can lead to serious health issues and can even be life-threatening.
If simpler treatment methods don’t work, it may be necessary to use a stent, a small tube, to reroute and bypass the damaged or leaking pancreatic duct. Additional treatment methods might involve medication to reduce the secretion of pancreatic fluids and, in severe cases, surgical intervention. However, because of the rarity of this condition, there is a lack of comparative studies on different treatment approaches.
What Causes Pancreatic Ascites?
Pancreatic Fistulas
A pancreatic fistula is a condition where fluid leaks persistently from a damaged pancreatic duct – a tube in the pancreas. This results in an abnormal connection between the duct and another lining surface or pocket. There are several causes of pancreatic fistulas, some due to medical procedures (iatrogenic) and others due to non-medical interventions (non-iatrogenic). Non-iatrogenic fistulas can occur due to long-term pancreas inflammation caused by alcohol misuse, or due to inflammation of the gallbladder.
Iatrogenic Causes
These are medical procedures that can result in a pancreatic fistula, including:
* A procedure that examines the gallbladder, bile ducts, and pancreas
* Surgeries involving the left kidney or left adrenal gland
* Surgery to remove all or part of the colon
* Partial removal of the pancreas
* Surgery to remove the spleen
* Pancreatic fistulas that are being drained externally, usually from pancreatic surgeries
* Disruptions in the front part of the pancreatic duct leading to the accumulation of fluid in a nearby area
* Disruptions in the back part of the pancreatic duct, leading to the formation of a fistula and fluid build-up
Non-iatrogenic Causes
These are causes not related to medical procedures, including:
* A fistula that persistently connects internally to the lining of the abdomen
* A pseudocyst or necrosis that is closed off by a wall
* Lack of a response to inflammatory reactions, leading to continued pancreatic fluid leakage
* Chronic pancreatitis (long-term inflammation of the pancreas)
Pancreatic Pseudocysts
A pancreatic pseudocyst develops when fluid leaks from the pancreatic duct because of infection, inflammation, injury, or formation of a fistula. Once the leaking pancreatic fluid is contained, it can lead to several complications, including the formation of a pseudocyst – a pocket filled with amylase and pancreatic enzymes surrounded by an irregular tissue wall. These pseudocysts usually form several weeks after a pancreatitis episode. A pseudocyst may not have symptoms, but it can also lead to abdominal pain, fever, loss of appetite, or signs of inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen. A leak or burst from a pseudocyst can lead to ascites – an accumulation of fluid in the abdomen. This reportedly occurs in about 6% to 14% of patients with pseudocysts. Leakage of pancreatic fluid into an area of dead tissue can delay the absorption of the wall-off necrotic material. Percutaneous and transmural endoscopic stenting, a method of opening a narrow or blocked duct, can be used to manage this condition.
Risk Factors and Frequency for Pancreatic Ascites
In the United States, the most common cause of ascites (a build-up of fluid in the abdominal cavity) is cirrhosis, accounting for around 85% of cases. Other causes include peritoneal carcinomatosis and cardiac failure, responsible for about 7% and 3% of cases, respectively. Nephrotic syndrome and tuberculosis are also causes, but less common. One rare type of ascites is pancreatic ascites, affecting around 3.5% of people with chronic pancreatitis, and making up just about 1% of all abdominal ascites cases. Pancreatic ascites is more prevalent in men and typically affects people aged between 20 and 50.
The rates of pancreatitis, which is linked to pancreatic ascites, can offer additional insight.
- Acute pancreatitis in the US is seen in 4.5 to 35 individuals per 100,000 population.
- Chronic pancreatitis has been reported in 42 to 73 adults per 100,000 population in the US.
- The yearly incidence rate of chronic pancreatitis in the US falls somewhere between 5 and 8 to 14 individuals per 100,000 adults.
- Each year, there are 34 cases of acute pancreatitis and 10 cases of chronic pancreatitis per 100,000 adults.
- Complications, such as internal pancreatic fistulae (including pancreatic ascites and pleural effusions), occur in approximately 7.3% of patients with chronic pancreatitis.
Around 14% of these cases will have both complications present, while 18% will have pancreatic pleural effusion only.
Signs and Symptoms of Pancreatic Ascites
Pancreatic ascites is a condition often found in people who have chronic pancreatitis. Patients mainly show symptoms like a gradual increase in stomach size or weight loss, occasionally coupled with pain and nausea. The weight loss is usually due to a lack of appetite rather than the accumulation of a lot of fluid in the stomach. Other signs include mild stomach discomfort and an increase in abdomen size.
Patients might also exhibit some non-specific symptoms such as fast heart rate, a state of functional blockage of the intestine, low blood pressure, and breathlessness. These symptoms occur mainly when the movement of the diaphragm is damaged or when there are associated fluid accumulations in the chest.
Based on the severity of the pancreatitis and the size and characteristics of the leak in the pancreatic duct, symptoms’ intensity varies. Around half of the patients with pancreatic ascites also have fluid accumulation in the chest. These people may have symptoms like cough, chest pain, shortness of breath, and extreme difficulty in breathing when exerting themselves. It’s possible that chronic pancreatitis history exists due to excessive alcohol consumption, as around 3.5% of these patients develop pancreatic ascites. It’s also common to find a recent history of abdominal injury or a procedure that involves using an ultrasound to guide a needle into the pancreas.
- Gradual increase in stomach size
- Weight loss
- Mild stomach discomfort
- Fast heartbeat
- Low blood pressure
- Breathlessness
- Chest pain (in some cases)
- Difficulty breathing when exerting oneself (in some cases)
However, the medical history of many patients doesn’t reveal previous instances of acute pancreatitis. Still, about one-third of patients share a recent history of an acute pancreatitis attack. The physical exam often shows a significant amount of fluid accumulation in the abdomen with noticeable shifting dullness and fluid waves, but usually without any stomach tenderness. Nothing in the physical examination can specifically point to the pancreas as the cause of previously undiagnosed fluid accumulation in the stomach. A thorough history and the results of a diagnostic procedure to remove a fluid sample from the abdomen typically guide the next steps.
Testing for Pancreatic Ascites
Assessment for chronic pancreatitis and related issues often require a procedure called diagnostic paracentesis. Additional imaging and laboratory testing may be needed as well.
Diagnostic Paracentesis
The American Association for the Study of Liver Diseases recommends a procedure called diagnostic paracentesis as the first step in evaluating new abdominal fluid buildup, also known as ascites. This procedure is safe, cost-effective and can provide crucial information for diagnosis. Doctors recommend conducting this procedure for all new cases of ascites. Tests on the fluid drawn during this procedure like amylase level, cell count, culture, gram stain, cytology, and serum protein can help confirm whether you have pancreatic ascites or point to another diagnosis such as:
– Protein concentration in the ascitic fluid
– If the protein level is greater than 3 g/dL
– Levels less than 1.5 g/dL could suggest possible spontaneous bacterial peritonitis or cirrhosis
– Ascites fluid amylase level
– Greater than 1000 (international units) IU/L
– Levels much higher (3 to 6 times) than the serum level
The results can also indicate if the ascites are caused by pancreatic disease or other conditions such as liver cirrhosis or heart failure.
Bacterial culture on the ascitic fluid is often conducted if there’s suspicion of spontaneous bacterial peritonitis, this is indicated by a polymorphonuclear count equal to or exceeding 250 cells/mm³ and a positive response to a 48-hour regimen of antibiotics. If the patient is due to start a course of antibiotics, then a bacterial culture is a must.
Diagnostic Imaging
Abdominal CT Scan
An abdominal CT scan can pinpoint pancreatic pseudocysts and detect small amounts of fluid in the peritoneum which tends to gather mainly in Morrison pouch and pelvis. It can also identify signs of chronic pancreatitis such as:
– Collapsed or partially collapsed pseudocysts
– Diffuse parenchymal glandular atrophy
– Dilated main pancreatic duct
– Pancreatic calcifications
X-ray and abdominal ultrasound
Plain radiographs and abdominal ultrasounds can have some value in evaluating pancreatic ascites but are limited. Some indicators on an abdominal x-ray could be a blurred outline of soft tissues, bulging flanks, and increased spacing of the small bowel. While an abdominal ultrasound may show internal fluid, these findings are not unique or specific to pancreatic ascites.
Advanced imaging
Magnetic resonance cholangiopancreatography (MRCP) with secretin stimulation is an advanced imaging method that can provide visuals of the pancreatic duct and any leaks or abnormalities. Secretin is a hormone that triggers pancreatic secretions and improves the sensitivity of the MRCP by about 50%. This imaging technique is now recommended in guidelines for evaluating the pancreatic duct. This is particularly helpful in patients who are not good candidates for or want to avoid another technique called endoscopic retrograde cholangiopancreatography (ERCP). More successful than CT, the MRCP provides visuals of the pancreatic duct correlating up to 91% with ERCP but without the need for endoscopy.
Some limitations include the need for secretin administration for optimal viewing and less detection of ductal disruption if the stenting is in place and working well. Even though this is a very good imaging method for pancreatic ductal anatomy, its utilization is often lower due to unfamiliarity, cost, logistical obstacles, and limited access or availability of secretin.
Treatment Options for Pancreatic Ascites
Pancreatic ascites management is based on three major interventions: medication, endoscopy, and surgery. Usually, the method is to initially try medication, then endoscopy, and finally, resort to surgery if the preceding methods fail.
Patients with mild pancreatic ascites are usually offered medication as a first-line treatment. This is because about a third of patients might get better without further intervention. The treatment generally sees the patient not eating or drinking anything, instead receiving nourishment through total parenteral nutrition (TPN) or total enteral nutrition (TEN). Research indicates TEN is preferred as it seems less likely to cause negative reactions like infections. This methodology is possibly due to TEN causing fewer alterations to the important gut bacteria compared to TPN. Also, any fluid or mineral imbalances in the body are carefully monitored and adjusted through this treatment.
Certain medications such as octreotide or somatostatin combined with diuretics may also be used. They have the effect of reducing the activity of the pancreas, paving the way for healing damaged pancreatic ducts. Additionally, intermittent therapeutic paracentesis, which involves removing fluid from the abdomen, can relieve discomfort for those with ascites, or a build-up of fluid in the abdomen.
The exact duration of this conservative medical treatment remains unknown; however, a 4 to 6-week course is generally considered suitable. Experimentation with a triple-drug therapy (involving somatostatin, gabexate mesylate, and imipenem/cilastatin) has shown promising results in animal models of pancreatic ascites.
If medication doesn’t work, an endoscopic procedure called ERCP (Endoscopic Retrograde Cholangiopancreatography) can be done. It helps identify any abnormalities and also allows an immediate, suitable intervention to be carried out. This procedure involves the placement of a stent (a kind of tube) at the outlet of the pancreatic duct, which decreases pressure inside the duct and diverts pancreatic fluids to the small intestine — assisting the healing process. As a rule, the stent should be optimally located to cover the duct disruption area for the best outcome. This intervention is frequently performed under fluoroscopic guidance.
In some complex cases, where there is pancreatic necrosis or substantial ductal injuries, stenting may not be completely successful. When stent placement proves inefficient, or when the leakage comes from what we call a “disconnected duct syndrome,” further interventions may be required, including transluminal stenting (via an organ naturally connecting with the body surface) or surgical interventions. Under these conditions, a collective, multidisciplinary approach is often necessary.
Finally, surgical treatment is usually the last resort, reserved for cases where medication and endoscopic interventions have failed or where there are significant disruptions in the pancreatic duct. Here, the patient must be kept on TPN or TEN for 4 to 6 weeks. In hard-to-cure cases with no success just from stenting caused by a completely disconnected pancreatic duct, surgery may be recommended. Needless to say, any surgical intervention should be based on a careful assessment of the patient’s condition and the potential risks and benefits. It may also require input and cooperation from various specialists, so the patient could be referred to a tertiary center that specializes in complex surgeries.
What else can Pancreatic Ascites be?
Pancreatic ascites, or fluid accumulation in the abdomen due to inflammation of the pancreas, is commonly seen in people with chronic pancreatitis, particularly those with a history of heavy drinking. If there’s no evidence of excessive alcohol consumption, other causes of ascites related to liver damage, or cirrhosis, should be explored. This could be from infections or other causes. Apart from cirrhosis, conditions that lead to fluid build-up in the abdomen with a high SAAG (serum-ascites albumin gradient) value include blockage of the liver or heart veins, right heart failure, and others.
Other causes of fluid build-up in the abdomen include specific conditions such as:
- Enteric Duplication Cysts: Uncommon birth defects that occur in the digestive tract. When they are connected to the pancreas, they can cause recurring pancreas attacks in children.
- Nephrotic Syndrome: This condition is considered when there’s fluid in the abdomen, together with other specific history, examination, and test results. Symptoms include swelling that starts around the eyes and legs and gradually spreads, weight gain, fluid build-up in the abdomen, and pleural effusions or fluid in the lungs. Sometimes, there may be blood in the urine or high blood pressure, but these are not consistent.
- Peritoneal Carcinomatosis: This refers to the spread of cancer to the surfaces of the abdominal organs. The two main symptoms are fluid build-up in the abdomen and bowel obstruction, but they are found in less than half the patients.
- Peritoneal Tuberculosis: This is where the tuberculosis infection has spread to the abdominal cavity. It typically happens after the rupture of diseased lymph nodes in the abdomen. The most common presentation is fluid build-up in the abdomen.
- Portal Hypertension: This is a condition where the pressure in the liver veins is high. This can lead to increased blood volume, increased heart output, and eventually fluid build-up in the abdomen.
What to expect with Pancreatic Ascites
The outlook for patients with pancreatic ascites, a condition where fluid builds up in the abdomen, has improved thanks to new endoscopic procedures. Roughly a third of those with pancreatic ascites can get better with standard medical care. In addition, another treatment where a small tube or stent is placed into the pancreas using an endoscope has a success rate of 82% to 100%.
A surgical approach is usually suggested for patients where initial medical and endoscopic treatments didn’t work. Although the risk of dying from this procedure can be as high as 15% to 25%, this risk diminishes when the procedure is done by experienced practitioners. Recent evidence shows that using endoscopic procedures has led to increased survival rates, less time spent in the hospital, and lower chances of the condition recurring.
Possible Complications When Diagnosed with Pancreatic Ascites
Pancreatic ascites, a condition where fluid builds up in the abdomen, can be treated effectively using either conservative methods or by placing a stent in the pancreatic duct during an endoscopic procedure, especially when there is a noticeable rupture in the pancreatic duct. Despite its efficacy, the stent placement procedure does carry some risks, including the potential for inflammation of the pancreas and complications with the guide wire used during the procedure, which could result in a perforation or tear. Additionally, due to the use of medical tools, the procedure comes with a heightened risk for infectious conditions like cholangitis or infected cysts.
The stent itself also carries some risks; it can get blocked, become infected, or move to remote areas of the pancreatic duct, which could make it hard to retrieve. If a stent is left in the pancreas for a prolonged period, it can even lead to similar changes as those seen in long-term pancreatitis. Therefore, in most cases, it is recommended to remove the stent, usually within a four to six week period. On a positive note, the chance of pancreatic ascites returning is less with the endoscopic intervention as compared to just using conservative medical management, though concrete data to support this claim is not present.
Risks associated with stent placement:
- Acute post-procedural pancreatitis
- Possible perforation due to guide wire complications
- Increased risk for cholangitis
- Infected pseudocyst
- The stent could become blocked or infected
- Migration of the stent to distal pancreatic duct
- Chronic pancreatitis-like changes due to prolonged stent placement
Recovery from Pancreatic Ascites
Patients with pancreatic fluid leakage in the abdomen (pancreatic ascites) and “ductal leaks”, or leaks in the tubes transporting body fluids, are often in poor health. However, their recovery is greatly influenced by the level and kind of physical and nutritional support they get. This could involve nutritional services and management of feeding through an IV line (total parenteral nutrition) or through the digestive system (enteral nutrition), use of medications that neutralize stomach acid or reduce its production, proper management of their other medical conditions, correct usage of antibiotics and antifungals. It also includes managing surgical drains and washouts, supporting their liver function, intake of probiotics, mental health counselling, avoiding muscle wasting, and incorporating physical and occupational therapy into their treatment plan.
Muscle wasting, known as sarcopenia, can be effectively prevented by starting physical exercise programs when the patient is first admitted to the hospital. Enhanced support and recovery programs, including resistance training, can lead to shorter hospital stays, less muscle wastage, and improve overall health outcomes.
Preventing Pancreatic Ascites
The top causes of pancreatitis, an inflammation of the pancreas, are things you can control, such as excessive alcohol consumption and gallstones. By maintaining a balanced diet and regular exercise, you can potentially prevent the formation of gallstones. Also, keeping alcohol consumption to a minimum or even avoiding it completely can help you avoid pancreatitis and its related problems.
