A53-23 A Rare Case of Spontaneous Bacterial Peritonitis in the Setting of Pancreatic Ascites

Pancreatic ascites occurs due to pancreatic duct leakage, rupture of a pancreatic pseudocyst, or severe necrotizing pancreatitis. Pancreatic ascites should be differentiated from other causes of ascites, as treatment may differ. Management includes supportive care, endoscopic stenting, somatostatin analogs, or surgical intervention in severe cases. Spontaneous bacterial peritonitis (SBP) caused by pancreatic ascites is very rare, as SBP is almost exclusively caused by cirrhosis with portal hypertension, where mono-microbial translocation occurs. Pancreatic ascites, however, is the result of pancreatic secretion leakage, and SBP may be a result of direct polymicrobial contamination from the hepatobiliary or gastrointestinal tract. We present a rare case of SBP in the setting of pancreatic pseudocyst rupture, pancreatic necrosis, and pancreatic duct leakage. A 63-year-old white female with a history of hypertension and chronic idiopathic pancreatitis presents with nausea, vomiting, and abdominal pain—no history of drinking, smoking, or illicit drug use. Upon presentation to the emergency department, she was febrile, tachycardic, tachypneic, and had low mean arterial pressure requiring vasopressors. She was also in severe acute hypoxic respiratory distress requiring emergent intubation. Laboratory findings showed elevated WBC, lactic acid, and lipase. CT of the abdomen and pelvis showed acute pancreatic inflammation and a large non-loculated pseudocyst, along with moderate ascites. Ascitic fluid analysis showed severely elevated amylase, along with a low serum-ascites albumin gradient, indicating non-portal hypertension causes of ascites. Ascitic fluid also showed severely elevated polymorphonuclear leukocytes, indicating SBP. Empiric Ceftriaxone was initiated. Her septic shock was complicated by hemorrhagic shock in the setting of hemorrhagic pancreatitis. Despite treatment, her multiorgan failure progressively worsened, and she passed. Causes of pancreatic ascites include chronic pancreatitis, pancreatic trauma (such as duct rupture), pancreatic pseudocyst rupture, or necrotizing pancreatitis. Treatment for pancreatic ascites is non-standard and lacks guidelines due to the condition’s rarity. Thus, treatment is modeled after guidelines for the treatment of SBP secondary to a decompensated cirrhosis. The most common bacteria implicated in SBP are Gram-negative enteric bacteria, with E. coli being the most prevalent. The American Association for the Study of Liver Diseases (AASLD) guidelines state that third-generation cephalosporins (ceftriaxone, cefotaxime) are first-line. This case highlights the importance of considering SBP when treating patients for pancreatic ascites. It is also essential to treat the underlying factors of ascites, such as pancreatitis. Proper and timely treatment of both SBP and pancreatitis is crucial in reducing complications and mortality in these patients. This abstract is funded by: None