P0082 - Recurrent Chylous Effusions and Fibrosis After Severe Acute Pancreatitis

Gabriel Gonzales, DO¹, Sheila Rastegari, DO¹, Elizabeth Nguyen, DO¹, Long Hoang, DO^2
1Medical City Fort Worth, Fort Worth, TX; ²UNT Health Science Center, Fort Worth, TX

Introduction: Following acute pancreatitis, patients can suffer complications related to injury from intense inflammation. Here we present a patient with refractory ascites for several months after resolution of an initial pancreatitis episode which was ultimately found to be chylous. Further investigation revealed the patient was suffering from underlying retroperitoneal fibrosis (RPF). Following resolution of acute pancreatitis, the presence of RPF is an important consideration in the setting of persistent chylous ascites and abdominal pain.

Case Description/Methods: A 42 year old female with history of recurrent pancreatitis presented with severe pancreatitis complicated by pleural effusions, ascites, pyloric edema, and intra-abdominal adhesions. In the following months, she developed recurrent ascites which was attributed to complications from pancreatitis and subsequent malnutrition. Ultimately, the ascites was found to be chylous, suggesting lymphatic involvement. After three months, imaging demonstrated persistent pancreatic inflammation and a poorly defined retroperitoneal mass. Biopsy showed fibrotic tissue with fat necrosis. Extensive evaluation was inconclusive, including medication review, EUS, PET-CT, and testing for IgG4 disease and tuberculosis. She also developed non-cirrhotic portal hypertension, biliary obstruction, hydronephrosis, and IVC compression. Ultimately, a diagnosis of retroperitoneal fibrosis was made. The patient was initiated on steroids with plan for transition to rituximab.

Discussion: While pancreatitis can be complicated by ascites, elevated fluid triglycerides are not typical. In this case, the etiology of chylous ascites was RPF, a progressive disease characterized by retroperitoneal inflammatory and fibrous tissue. RPF can be either idiopathic (sometimes associated with IgG4 disease), or secondary to an underlying process such as malignancy or radiation. Disease overlap was considered given the patient's history of recurrent pancreatitis, however all testing was negative including IgG4. The etiology of her ascites remained obscure due to persistent pancreatic inflammation and malnutrition; RPF was only diagnosed after her disease progressed to involve the biliary ducts and intra-abdominal vessels. Early evaluation for chylous ascites can lead to prompt diagnosis and avoidance of progressive disease, and thus should remain an important diagnostic tool to consider once pancreatic ascites has been excluded.


Disclosures:


Gabriel Gonzales, DO¹, Sheila Rastegari, DO¹, Elizabeth Nguyen, DO¹, Long Hoang, DO². P0082 - Recurrent Chylous Effusions and Fibrosis After Severe Acute Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.