P1814 - Inguinal Necrosis: An Unusual Complication of Pancreatic Pseudocyst

Christina J. Santana, MD¹, Jinye Liu, DO¹, Amy Chang, MD¹, Abdulazeez Swaiti, MD², Christin Wilkinson, MD², Stephanie Ibarra Lepe, MD¹, Matthew Tugman, BA³, Michelle Cooley, BS³, Catherine Gray, BS³, Saeed Graham, MD², Zarak Khan, MD⁴, MaryKate Kratzer, MD¹, Karissa Lambert, MD⁴, Hassam Ali, MD², Rahul Pamarthy, MD², Prashant Mudireddy, MD^4
1East Carolina University Medical Center, Greenville, NC; ²East Carolina University, Greenville, NC; ³East Carolina University Brody School of Medicine, Greenville, NC; ⁴East Carolina Gastroenterology, Greenville, NC

Introduction: Acute pancreatitis can lead to peripancreatic fluid collections, classified by their contents. Pseudocysts are liquid collections, while acute necrotic collections contain both liquid and solid debris. Historically, management involved surgical drainage, but technological advancements have shifted the approach to less invasive methods. Endoscopic cystogastrostomy, which connects the fluid collection to the digestive tract for drainage, is now the first-line treatment. Most complications are technical or related to bleeding. This case highlights a rare and unexpected complication that underscores the importance of patient-specific management.

Case Description/Methods: A 36-year-old man with a history of chronic pancreatitis secondary to alcohol use disorder presented for an enlarging left inguinal mass. Imaging studies revealed a large pancreatic pseudocyst that extended from the pancreas along the left retroperitoneum and into the left upper inguinal fossa. Patient subsequently underwent an endoscopic ultrasound-guided cystogastrostomy, following the placement of a stent, approximately 1.2 liters of purulent fluid was drained. Two days later, patient developed worsening left sided inguinal groin pain with new overlying skin changes. Later developing overlying skin changes suspicious for necrosis, although a drain was placed in the left paracolic area for management, the patient was ultimately taken to the OR for an excisional debridement that was converted into an exploratory laparotomy. Findings then suggested that his gastric contents were preferentially draining through the cystogastrostomy stent and into the inguinal herniation.

Discussion: Though much safer than surgical or open drainage, EUS-guided transmural drainage of pancreatic collections still has complications. Early issues are usually technical failures such as mal-deployment of stents or perforation caused by the separation of the cyst wall and the stomach during the procedure. Delayed complications involve stent blockage by food or solid debris that have the potential to lead to secondary infections. Unique to this case was the extent of the pseudocyst, its size and connection into an existing inguinal hernia, and the low intra-abdominal pressure. Although less invasive and associated with improved healing times, this case emphasizes the importance of patient centered management selection and an understanding of the risk factors that could potentially predict complications.



Disclosures:


Christina J. Santana, MD¹, Jinye Liu, DO¹, Amy Chang, MD¹, Abdulazeez Swaiti, MD², Christin Wilkinson, MD², Stephanie Ibarra Lepe, MD¹, Matthew Tugman, BA³, Michelle Cooley, BS³, Catherine Gray, BS³, Saeed Graham, MD², Zarak Khan, MD⁴, MaryKate Kratzer, MD¹, Karissa Lambert, MD⁴, Hassam Ali, MD², Rahul Pamarthy, MD², Prashant Mudireddy, MD⁴. P1814 - Inguinal Necrosis: An Unusual Complication of Pancreatic Pseudocyst, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.