Extensive Hemorrhagic Ascites and Peritoneal Necrosis in Acute Pancreatitis: Case Presentation and Review of Literature

Radu Moldovan; Catalin Cosma; Dragos Molnar; Marian Botoncea; Vlad Olimpiu Butiurca; Calin Molnar

doi:10.33695/rojes.v7i1.137

Radu Moldovan George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures,SCJU Tg.Mures Chirurgie 1
Catalin Cosma SCJU Tg.Mures Chirurgie 1
Dragos Molnar George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures,SCJU Tg.Mures Chirurgie 1
Marian Botoncea George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures,SCJU Tg.Mures Chirurgie 1
Vlad Olimpiu Butiurca George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures,SCJU Tg.Mures Chirurgie 1
Calin Molnar George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures,SCJU Tg.Mures Chirurgie 1

DOI: https://doi.org/10.33695/rojes.v7i1.137

Keywords: acute pancreatitis, hemorrhagic ascites, pancreatic necrosis, peritoneal necrosis, necrotizing pancreatitis, emergency surgery

Abstract

Introduction: Severe Acute Pancreatitis may rarely progress to catastrophic intra-abdominal complications including hemorrhagic ascites and diffuse peritoneal necrosis. These findings reflect advanced enzymatic tissue destruction, severe systemic inflammatory response, and high mortality risk. Emergency surgical intervention remains challenging, particularly in patients presenting with acute abdomen and rapid hemodynamic deterioration.

Material & Method: We present the case of a patient admitted with severe acute pancreatitis complicated by extensive hemorrhagic ascites and diffuse peritoneal necrosis requiring emergency surgical management. Clinical presentation, laboratory findings, computed tomography imaging, intraoperative findings, surgical treatment, and postoperative evolution were analyzed. A focused literature review was additionally performed using PubMed/MEDLINE and Google Scholar databases regarding necrotizing pancreatitis associated with hemorrhagic ascites, pancreatic necrosis, vascular complications, abdominal compartment syndrome, and emergency surgical intervention.

Results: Computed tomography demonstrated severe acute pancreatitis with extensive intra-abdominal fluid collections and suspected pancreatic necrosis. Due to progressive clinical deterioration and signs of surgical abdomen, emergency exploratory laparotomy was performed. Intraoperatively, large-volume hemorrhagic ascites associated with extensive peri-pancreatic and diffuse peritoneal necrosis was identified. Surgical management included evacuation of hemorrhagic collections, necrosectomy, extensive abdominal lavage, and drainage. Postoperatively, the patient required intensive multidisciplinary support because of persistent systemic inflammatory response and severe metabolic imbalance.

Conclusion: Hemorrhagic ascites associated with diffuse peritoneal necrosis represents a rare but severe manifestation of necrotizing acute pancreatitis. Early recognition, prompt multidisciplinary assessment, and individualized surgical management are essential in critically ill patients presenting with advanced intra-abdominal complications.

References

1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111. doi:10.1136/gutjnl-2012-302779.
2. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1-e15. doi:10.1016/j.pan.2013.07.063.
3. Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019;14:27. doi:10.1186/s13017-019-0247-0.
4. Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019;156(7):1994-2007.e3. doi:10.1053/j.gastro.2019.01.269.
5. Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: management of pancreatic necrosis. Gastroenterology. 2020;158(1):67-75.e1. doi:10.1053/j.gastro.2019.07.064.
6. van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491-1502. doi:10.1056/NEJMoa0908821.
7. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JHC. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. doi:10.1148/radiology.174.2.2296641.
8. Bradley EL III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg. 1993;128(5):586-590. doi:10.1001/archsurg.1993.01420170122019.
9. Boxhoorn L, Voermans RP, Bouwense SAW, Bruno MJ, Verdonk RC, Boermeester MA, et al. Acute pancreatitis. Lancet. 2020;396(10252):726-734. doi:10.1016/S0140-6736(20)31310-6.
10. Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute technical review. Gastroenterology. 2018;154(4):1103-1139. doi:10.1053/j.gastro.2018.01.032.
11. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400-1415. doi:10.1038/ajg.2013.218.
12. Garg PK, Singh VP. Organ failure due to systemic injury in acute pancreatitis. Gastroenterology. 2019;156(7):2008-2023. doi:10.1053/j.gastro.2018.12.041.
13. Beger HG, Rau BM. Severe acute pancreatitis: Clinical course and management. World J Gastroenterol. 2007;13(38):5043-5051. doi:10.3748/wjg.v13.i38.5043.
14. Petrov MS, van Santvoort HC, Besselink MG, van der Heijden GJ, Windsor JA, Gooszen HG. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch Surg. 2008;143(11):1111-1117. doi:10.1001/archsurg.143.11.1111.
15. Mier J, León EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997;173(2):71-75. doi:10.1016/S0002-9610(96)00425-4.
16. van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018;391(10115):51-58. doi:10.1016/S0140-6736(17)32404-2.
17. De Waele JJ, Leppäniemi AK. Intra-abdominal hypertension in acute pancreatitis. World J Surg. 2009;33(6):1128-1133. doi:10.1007/s00268-009-9994-5.
18. Koutroumpakis E, Wu BU, Bakker OJ, Dudekula A, Singh VK, Besselink MG, et al. Admission hematocrit and rise in blood urea nitrogen at 24 h outperform other laboratory markers in predicting persistent organ failure and pancreatic necrosis in acute pancreatitis. Am J Gastroenterol. 2015;110(12):1707-1716. doi:10.1038/ajg.2015.370.
19. Barge JU, Lopera JE. Vascular complications of pancreatitis: role of interventional therapy. Korean J Radiol. 2012;13 Suppl 1:S45-S55. doi:10.3348/kjr.2012.13.S1.S45
20. Isaji S, Takada T, Mayumi T, Yoshida M, Wada K, Yokoe M, et al. Revised Japanese guidelines for the management of acute pancreatitis 2015. J Hepatobiliary Pancreat Sci. 2015;22(6):433-445. doi:10.1002/jhbp.259.
21. Mentula P, Hienonen P, Kemppainen E, Puolakkainen P, Leppäniemi A. Surgical decompression for abdominal compartment syndrome in severe acute pancreatitis. Arch Surg. 2010;145(8):764-769. doi:10.1001/archsurg.2010.132
22. Windsor JA, Kanwar S, Li AGK, Barnes E, Guthrie JA, Spark JI, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut. 1998;42(3):431-435. doi:10.1136/gut.42.3.431.
23. Bollen TL, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, et al. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis. Am J Gastroenterol. 2012;107(4):612-619. doi:10.1038/ajg.2011.438.
24. Zerem E. Ascites in acute pancreatitis: A window into disease severity. World J Gastroenterol. 2025;31(43):112797. doi:10.3748/wjg.v31.i43.112797.
25. Bush N, Rana SS. Ascites in acute pancreatitis: clinical implications and management. World J Gastroenterol. 2021;27(32):5291-5306. doi:10.3748/wjg.v27.i32.5291
26. Gloor B, Müller CA, Worni M, Martignoni ME, Uhl W, Büchler MW. Late mortality in patients with severe acute pancreatitis. Br J Surg. 2001;88(7):975-979. doi:10.1046/j.0007-1323.2001.01813.x.
27. Rana SS, Sharma RK, Gupta R. Endoscopic management of pancreatic ascites due to duct disruption following acute necrotizing pancreatitis. JGH Open. 2018 Dec 12;3(2):111-116. doi: 10.1002/jgh3.12113. PMID: 31061885; PMCID: PMC6487829.
28. Boreham, B., & Ammori, B. J. (2003). A prospective evaluation of pancreatic exocrine function in patients with acute pancreatitis: correlation with extent of necrosis and pancreatic endocrine insufficiency. Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.], 3(4), 303–308. https://doi.org/10.1159/000071768
29. Ranson J. H. (1982). Etiological and prognostic factors in human acute pancreatitis: a review. The American journal of gastroenterology, 77(9), 633–638.
30. Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, et al. IAP guidelines for the surgical management of acute pancreatitis. Pancreatology. 2002;2(6):565-573. doi:10.1159/000067684.
31. Büchler MW, Gloor B, Müller CA, Friess H, Seiler CA, Uhl W. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg. 2000;232(5):619-626. doi:10.1097/00000658-200011000-00001.
32. Werner J, Feuerbach S, Uhl W, Büchler MW. Management of acute pancreatitis: from surgery to interventional intensive care. Gut. 2005;54(3):426-436. doi:10.1136/gut.2003.035907.
33. Bassi C, Falconi M, Butturini G, et al. Early complications of severe acute pancreatitis. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6978/
34. Rau, B., Bothe, A., & Beger, H. G. (2005). Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery, 138(1), 28–39. https://doi.org/10.1016/j.surg.2005.03.010
35. Werge M, Novovic S, Schmidt PN, Gluud LL. Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology. 2016;16(5):698-707. doi:10.1016/j.pan.2016.07.004.