C0655 - Elevated Ascitic Fluid Amylase? Think Twice It Could Be a Foreshadowing of Intestinal Perforation

Gabriela M. Negron-Ocasio, MD¹, Paola Laracuente Roman, MD², Luis Reimon-Garcia, MD¹, Josue Ocasio, MD³, Juan J. Adams Chahin, MD¹, Pedro Vargas-Otero, MD³, Artemio Santiago-Molina, MD^3
1University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico; ²University of Puerto Rico School of Medicine Internal Medicine Program, San Juan, Puerto Rico; ³University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico

Introduction: Elevated ascitic fluid amylase concentration is characteristic of pancreatic ascites. Nevertheless, ascitic amylase values greater than 2000 u/L can also be seen in intestinal perforation. We present a case of a patient without evident risk factors for fungal peritonitis whose ascitic fluid was notable for yeast and elevated amylase with a final diagnosis of intestinal perforation.

Case Description/Methods: A 54-year-old female with a medical history of metastasized transitional cell urethral cancer arrived at our institution due to persistent non-bloody vomiting, diffuse abdominal pain, and worsening abdominal distension for a month. Initial evaluation was a remarkable food distended, tense abdomen with normoactive bowel sounds and positive fluid wave. Images were remarkable for large amounts of ascites, with a faint enhancement of the peritoneal surface consistent with acute peritonitis and findings concerning partial small bowel obstruction with free retroperitoneal air of unknown origin. The patient was started on intermittent suction via a nasogastric tube. Diagnostic and therapeutic paracentesis was performed. CT urogram was performed due to concern of bladder perforation, which was remarkable for diverticular microperforation. Ascitic fluid analysis was consistent with secondary peritonitis, with yeast species and markedly elevated ascitic amylase at >7,500u/L in the setting of normal pancreatic enzymes. Empiric coverage for fungal peritonitis was started with caspofungin. Hospitalization was complicated by shock and acute abdomen. Emergent imaging revealed duodenal jejunal mesenteric ischemia with perforation of the proximal jejunum and peritonitis. The patient underwent exploratory laparotomy with palliative gastrostomy, lysis of adhesions, and peritoneal lavage. After the intervention, blood cultures came back positive for candida glabrata. The patient completed therapy for fungemia and was discharged to hospice care.

Discussion: Candida peritonitis is most seen as secondary peritonitis. It generally occurs as a result of translocation of micro-organisms across the bowel wall, perforation of a hollow viscus, or instrumentation of the gastrointestinal tract. It is associated with high morbidity and mortality. This case raises awareness of careful evaluation of elevated ascitic amylase with concomitant yeast species in ascitic fluid gram stain, as they can both be indicators of intestinal perforation where a surgical approach can be lifesaving.


Disclosures:


Gabriela M. Negron-Ocasio, MD¹, Paola Laracuente Roman, MD², Luis Reimon-Garcia, MD¹, Josue Ocasio, MD³, Juan J. Adams Chahin, MD¹, Pedro Vargas-Otero, MD³, Artemio Santiago-Molina, MD³. C0655 - Elevated Ascitic Fluid Amylase? Think Twice It Could Be a Foreshadowing of Intestinal Perforation, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.