Successful ERCP with Pancreatic Duct Stenting for Pancreatic Duct Leak in a 15 Y.O. Male

Chief Complaints

A 15-year-old male patient with body mass index (BMI) 19 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of progressive abdominal distension and abdominal pain for one month. He also had nausea, non-bilious, non-projectile vomiting, abdominal tightness after meals, and loss of appetite.

The patient had no significant past medical history, was not on any regular medications before admission, and had no known drug allergies.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. Abdominal examination revealed uniform abdominal distension with tenderness, predominantly over the upper abdomen. No other significant systemic abnormalities were present.

Upon admission to PACE Hospitals, the Gastroenterology team conducted a detailed clinical assessment, including a review of the patient's symptoms and physical examination. Laboratory investigations and imaging studies, including ultrasonography (USG) of the abdomen, contrast-enhanced computed tomography (CT) of the abdomen, and Doppler ultrasound of the lower limbs, were performed to identify the cause of the patient's abdominal symptoms and assess associated vascular complications.

The imaging studies revealed moderate to large ascites, a 3.7 × 1.9 cm walled-off pancreatic necrosis (WOPN) in the proximal body of the pancreas communicating with the pancreatic duct (PD), and a filling defect in the right external iliac vein. Doppler ultrasound confirmed acute deep vein thrombosis (DVT) involving the right lower limb veins extending into the right iliac vein. ERCP pancreatography further demonstrated a pancreatic duct leak.

Based on the clinical, radiological, and endoscopic findings, the patient was advised to undergo Acute Pancreatitis Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department.

After a detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist and Hepatologist), a comprehensive evaluation was performed to determine the most appropriate management strategy. Considering the patient's acute pancreatitis complicated by a pancreatic duct leak, pancreatic ascites, walled-off pancreatic necrosis (WOPN), and right lower limb deep vein thrombosis (DVT), treatment was planned to address both the pancreatic and vascular complications.

Based on the clinical assessment, laboratory findings, imaging studies, and ERCP pancreatography confirming a pancreatic duct leak communicating with the WOPN, it was determined that Endoscopic Retrograde Cholangiopancreatography (ERCP) with Pancreatic Duct (PD) sphincterotomy and PD stenting was the most appropriate intervention. Simultaneously, anticoagulation therapy was initiated to treat the right lower limb deep vein thrombosis and reduce the risk of thromboembolic complications.

The patient and his family members were counselled regarding the diagnosis, planned endoscopic procedure, expected benefits, possible risks, postoperative recovery, anticoagulation therapy, dietary modifications, and the importance of regular follow-up, including scheduled pancreatic duct stent removal.

Following the treatment decision, the patient was scheduled to undergo Endoscopic Retrograde Cholangiopancreatography (ERCP) with Pancreatic Duct (PD) sphincterotomy and PD stenting in Hyderabad, at PACE Hospitals, under the expert care of the Gastroenterology Department.

The procedure involved the following steps:

• Patient Preparation and Anaesthesia: After obtaining informed consent and completing the pre-procedure evaluation, the patient was taken to the endoscopy suite and administered appropriate anaesthesia. Standard aseptic precautions and continuous monitoring were maintained throughout the procedure.

• Endoscopic Access and Cannulation: A side-viewing endoscope was advanced into the duodenum, and the major duodenal papilla was identified. The pancreatic duct was selectively cannulated using a guidewire under fluoroscopic guidance.

• Pancreatography and Duct Evaluation: Contrast pancreatography was performed, which demonstrated a pancreatic duct leak communicating with the walled-off pancreatic necrosis (WOPN).

• Pancreatic Duct Sphincterotomy and Stent Placement: A pancreatic sphincterotomy was performed over the guidewire, following which a 5 Fr × 7 cm single-pigtail plastic pancreatic duct stent was successfully deployed across the ductal leak, with the distal end positioned within the walled-off pancreatic necrosis to facilitate internal drainage and promote healing.

• Completion of the Procedure: Adequate stent position and drainage were confirmed, and the endoscope was withdrawn. The procedure was completed successfully without any immediate procedure-related complications.

The post-procedure period was uneventful, and the patient remained hemodynamically stable throughout the hospital stay. He was closely monitored for abdominal pain, fever, drain output, and overall clinical recovery. Percutaneous catheter drainage was performed for pancreatic ascites, and the drain output gradually decreased, allowing safe removal of the catheter without recurrence of fluid accumulation. During hospitalization, he received supportive treatment for hydration, infection prevention, pain control, nutritional support, and management of the associated deep vein thrombosis with anticoagulation therapy. Follow-up imaging demonstrated persistent walled-off pancreatic necrosis with minimal residual pelvic fluid collection and partial recanalization of the right lower limb deep vein thrombosis.

Upon discharge, the patient was prescribed medications for infection prevention, gastric protection, pain relief, anticoagulation therapy, and overall supportive recovery.

The patient was advised to follow a fat-free diet, maintain adequate hydration, continue anticoagulation therapy as prescribed, and adhere to dietary recommendations to reduce the risk of recurrent pancreatitis. He was also advised to attend scheduled follow-up visits, including pancreatic duct stent removal, and seek medical attention if symptoms recurred.

The patient was advised to report immediately to the emergency ward at PACE in case of development of symptoms such as fever, severe abdominal pain, persistent vomiting, increasing abdominal distension, swelling or pain in the lower limbs, bleeding, breathing difficulty, or any other concerning symptoms.

The patient was advised to return for follow-up with the Gastroenterologist in Hyderabad at PACE Hospitals after 3 months.

This case highlights the successful management of acute pancreatitis complicated by pancreatic duct leak, pancreatic ascites, walled-off pancreatic necrosis (WOPN), and right lower limb deep vein thrombosis (DVT) using ERCP with pancreatic duct sphincterotomy, pancreatic duct stenting, and anticoagulation therapy. The patient showed good clinical improvement, underwent successful pancreatic duct stent removal during follow-up, and was discharged in a hemodynamically stable condition with dietary advice and regular follow-up.