EUS-guided Management of a Large Pancreatic Leak: Case Study

This clinical case study describes a 3-year-old male admitted with injuries to his liver and peripancreatic fluid collection, which was ultimately treated with endoscopic ultrasound (EUS) guided cyst-gastrostomy to allow for internal drainage and ultimate resolution of the symptoms and fluid collection.

Background

The patient, a 3-year-old male, presented with abdominal pain, vomiting and bruising of the abdomen. He was admitted to Children’s Hospital of Philadelphia (CHOP) with multiple intra-abdominal organ injuries to the liver, pancreas and adrenal gland.

Initial imaging included a computed tomography (CT) scan that demonstrated a grade II liver laceration, and grade III pancreatic laceration/injury. These injuries may include injury to the bile duct or pancreatic duct, leading to leakage of bile or pancreatic fluid into the abdominal cavity, respectively.

A large peri-pancreatic fluid collection developed, causing significant gastrointestinal and respiratory symptoms. The patient underwent successful endoscopic ultrasound-guided placement of a covered metal stent to provide internal drainage of the fluid collection, leading to a resolution of symptoms. He ultimately was able to be discharged after a follow-up endoscopic procedure for stent removal. 

Diagnostic findings

Diagnostic testing included both laboratory tests and imaging: 

• Blood work demonstrated elevated aminotransferases with AST 11,582 and ALT 5,985, along with elevated amylase 602, and lipase 7,869.
• Abdomen and pelvis CT demonstrated findings of grade II liver laceration and grade III pancreas injury. Other injuries showed a right adrenal hematoma and 7th rib fracture. (see Fig. 1) 

• An endoscopic retrograde cholangiopancreatography (ERCP) confirmed a left segmental bile leak. (See Fig. 2) 

• Follow-up CT – due to new symptoms of abdominal pain, vomiting, and respiratory distress – demonstrated a large, organized peri-pancreatic fluid collection consistent with a pancreatic pseudocyst. (See Figs. 3 & 4) 

Clinical course and treatment

After initial stabilization and assessing the degree of injury per the solid organ injury trauma pathway, the patient underwent an ERCP to identify the areas of injury in the biliary ducts, liver and pancreas.

The ERCP was able to identify a bile leak, which was treated with biliary sphincterotomy and placement of a biliary stent. At the time of the ERCP, the pancreas was unable to be accessed.

Over time, due to the continued leakage of pancreatic fluid into the abdominal cavity, the patient developed a large, organized fluid collection, as seen on an interval CT scan. (see Fig. 5) This caused significant compression on the stomach and diaphragm, leading to vomiting and difficulty breathing, respectively.

The decision was made to attempt an endoscopic ultrasound (EUS) guided placement of a covered metal mesh stent (See Fig. 6) to create an internal conduit for drainage of the fluid via the stomach, called a cyst-gastrostomy.

The patient underwent successful EUS-guided placement of a lumen apposing metal stent (LAMS) (see Fig. 7) with prompt drainage of the fluid and near immediate resolution of the symptoms. Approximately 2 liters of fluid were drained via the LAMS through the digestive tract in the first 24 hours after LAMS placement.  

A follow-up CT scan (see Fig. 8) obtained 5 days after the EUS procedure demonstrated significant decrease in size of the fluid collection.  

Outcomes

A standard-of-care follow-up endoscopy was performed two weeks after LAMS placement to assess the pseudocyst and remove the LAMS. The patient was able to be discharged the following day. 

One month after discharge, the patient had an outpatient follow-up and ultrasound performed, which did not reveal any residual fluid collection. 

Discussion

Patients with traumatic pancreatitis, depending on the grade of injury, may be managed conservatively with supportive care or may require multidisciplinary care utilizing advanced endoscopic interventions to help promote healing and minimize symptoms.

Most patients with pancreatic fluid collections can also be managed conservatively, as many will resolve on their own; however, when the fluid collection is large enough to cause persistent symptoms, then drainage is recommended. 

Historically surgical procedures to create cyst-gastrostomy were employed, but this was fraught with a high risk of complications. Percutaneous drains placed by interventional radiology can also be used, but can be uncomfortable for patients.  

Endoscopic-guided drainage procedures were also employed, but prior to the creation of the lumen apposing metal stent in 2011, there was risk of persistent fluid leak. LAMS provides a reliable conduit for internal drainage of a fluid collection via the digestive tract. The minimally invasive procedure is often a more comfortable intervention for patients and has a good safety record. 

At CHOP’s Level 1 Trauma Center, our experts in trauma provide world-class care. When there is involvement of the pancreas and/or liver, collaboration with advanced endoscopists within the Division of Gastroenterology, Hepatology and Nutrition is paramount for providing the full spectrum of care that may be needed for complex traumas. 

The authors are participants in CHOP’s Trauma Center, Pancreatic Disorders Program, and Kohl’s GI Nutrition and Diagnostic Center. Alexander Coe, MD, MEd, is a pediatric gastroenterologist with additional training and special expertise in advanced endoscopic procedures, such as ERCP and EUS. Gary W. Nace, Jr., MD, FACS, FAAP, is an attending surgeon with expertise in critical care and trauma.