Abstract Introduction Acute pancreatitis (AP) is one of the most common causes of gastrointestinal hospitalization in the United States. While overall mortality is approximately 1%, it rises to 30-40% in cases complicated by organ failure or necrosis. Pancreaticopleural fistula (PPF) is an uncommon sequela, accounting for less than 1% of pleural effusions and 0.4-7% of chronic pancreatitis cases. Pancreatorenal fistula (PRF) is even rarer, with only isolated reports in the literature. We present a rare case of necrotizing pancreatitis complicated by both PPF and PRF, along with splenic vein thrombosis, managed successfully with endoscopic therapy. Case Presentation A 30-year-old male with alcohol use disorder presented with severe epigastric pain radiating to the back, nausea, and persistent non-bloody emesis. Imaging confirmed acute pancreatitis despite serum lipase not exceeding three times the upper limit of normal, fulfilling two of three diagnostic criteria. He was managed with intravenous fluids and opioid analgesia. Within 48 hours, the patient developed worsening abdominal pain, hypoxemia requiring high-flow oxygen, and stage-2 acute kidney injury. His Modified Marshall Score 2 confirmed severe pancreatitis. Repeat CT demonstrated peripancreatic collections extending into the left anterior pararenal space, consistent with evolving PRF. Empiric Meropenem was initiated for suspected secondary infection. Progressive dyspnea prompted thoracentesis, which yielded 1 L of exudative pleural fluid with low glucose (38 mg/dL), elevated LDH (650 U/L), and markedly increased amylase (10,000 U/L), confirming PPF. Imaging later showed walled-off pancreatic necrosis (WON). Despite supportive care, pleural effusions recurred, prompting ERCP, which revealed pancreatic duct disruption. Endoscopic sphincterotomy with transpapillary stenting achieved rapid reduction of pleural drainage and clinical stabilization. The patient was discharged with new-onset diabetes on insulin therapy and close outpatient follow-up. Discussion This case illustrates the systemic and local complications of necrotizing pancreatitis, including PPF, PRF, WON, and splenic vein thrombosis. PPF typically presents with recurrent large pleural effusions and pleural fluid amylase 10,000 U/L. PRF, a rarer entity, signifies retroperitoneal extension of necrosis. Early recognition and a step-up approach, are critical. In this case, ERCP-guided ductal stenting diverted pancreatic secretions, allowing fistula closure and recovery. Conclusion This case underscores the severity of necrotizing pancreatitis, which can swiftly progress to multiorgan failure with complex fistulization. Despite walled-off necrosis and multiple fistulae, timely endoscopic stenting led to recovery. Persistent symptoms despite normalized enzymes warrant evaluation for complications, and pleural fluid analysis in recurrent effusions is essential. Early multidisciplinary collaboration and step-up management are key to improving survival. This abstract is funded by: None
Ramos et al. (2026) studied this question.