High Mortality in Patients with Cirrhosis and Severe Pancreatitis Who Need Pancreatic Fluid Drained

Patients with severe acute pancreatitis can develop both pancreatic necrosis and pancreatic fluid build up in the abdomen called pseudocyst. These can lead to various symptoms including compression of the stomach and small intestine leading to inability to eat, nausea and vomiting. Pseudocyst also can cause abdominal pain or become infected.

Physicians can drain the fluid through endoscopic ultrasound (EUS) guided transmural drainage using removable self-expandable metal stents (SEMS). The outcome of this procedure, however, has not been reported on patients with cirrhosis.

“Pancreatic necrosis, especially infected necrosis carries a significant mortality” says Prabhleen Chahal, MD, advanced endoscopist and pancreas specialist. “If on top of that, you have patients with another severe ailment like cirrhosis — that increases the risk of the procedure significantly.”

Dr. Chahal and her colleagues recently conducted a study comparing the outcomes of two groups of patients with pancreatitis necrosis and pseudodyst. One group had cirrhosis; the other did not. She presented their data at WCOG at ACG2017.

Two out of five patients died

Dr. Chahal and her colleagues looked at the case of five patients with cirrhosis and 25 without. Each patient received intravenous ciprofloxacin to decrease the risk of secondary infection. They used EUS imaging to determine the optimal puncture site of the collection and color doppler to exclude interposed vessels at the puncture site.

AXIOS stent across cystgastrostomy

Direct endoscopic view of infected pancreatic necrosis with large amount of pus.

The following are the pathology and results of the patients with cirrhosis:

Patients 1, 2 and 3 had pancreatic pseudocysts (PP), approximately 70 mm in size, located in the body or tail of the pancreas and each of them underwent successful placement of a lumen-apposing self-expandable metal stent (Hot AXIOS™ Stent; Boston Scientific).

Patient 1 developed upper gastrointestinal bleeding from the rupture of a pseudoaneurysm of the inferior division of the main splenic artery post cystogastrostomy placement requiring embolization. He ultimately developed severe sepsis and expired. Patients 2 and 3 experienced no adverse events with complete resolution of the PP.

Patient 4 presented with gastric outlet obstruction and cholangitis from a 200 mm walled off necrosis (WON) in the pancreatic head and underwent AXIOS stent placement successfully. Post procedure, however, he developed hypovolemic shock necessitating intensive care unit admission. He subsequently underwent three endoscopic necrosectomies before he expired due to hypoxic respiratory failure post gastrointestinal bleeding.

Patient 5 also had a large WON with complete disruption of the pancreatic duct. A fully covered self-expanding metal stent (FCSEM) was placed in him. He required multiple endoscopic necrosectomies and eventually developed acute cholangitis due to severe duodenal wall edema. Ultimately, the FCSEM was successfully removed with resolution of the WON after 165 days.

Multidisciplinary approach

Dr. Chahal says the fact that two patients with cirrhosis died after the procedure was not surprising. “That is a direct reflection of the underlying comorbidity and severity of illness,” she says. ”When we compared them to the other 25 patients who did not have cirrhosis, there’s a difference in mortality rates. For patients with cirrhosis two out of five died versus two out of 25 for patients without cirrhosis, so an 8 percent versus 40 percent mortality rate.”

She says the results indicate that physicians need to be mindful about how to approach patients with cirrhosis who have pancreatitis and need drainage or debridement of pancreatic fluid collections. “All of the providers need to be informed,” she says. “There should be a multidisciplinary care team that comes up with a plan, and they must understand the risks involved, that the risk of mortality can be significantly higher than when a patient has a healthy liver.”