Pancreatic Ascites Complicated by Salmonella Enteritidis Peritonitis: A Diagnostic Challenge and the Role of Surgical Source Control.

Pancreatic ascites is an uncommon complication of pancreatic disorders resulting from persistent leakage of pancreatic juice into the peritoneal cavity, most commonly due to disruption of the main pancreatic duct or rupture of a pancreatic fluid collection. Bacterial peritonitis complicating pancreatic ascites is rarely reported. We report the case of a 40-year-old man who presented with massive pancreatic ascites associated with a marked elevation of serum lipase. Analysis of the ascitic fluid strongly supported its pancreatic origin, and conservative management with enteral nutrition and a somatostatin analogue was initiated. One week after biliopancreatic magnetic resonance imaging, the patient developed sudden deterioration with septic shock, tense ascites, acute kidney injury, and purulent ascitic fluid. Emergency laparoscopy was performed because of concern for secondary peritonitis from an occult gastrointestinal perforation. Approximately 9 L of purulent ascites were evacuated, followed by extensive peritoneal lavage and drainage. No gastrointestinal perforation or other intra-abdominal source of contamination was identified. Peritoneal fluid cultures isolated a fully susceptible Salmonella enterica serovar Enteritidis, while blood cultures remained negative. Antibiotic therapy was subsequently de-escalated to amoxicillin-clavulanic acid based on antimicrobial susceptibility testing, and a full seven-day course was completed. The postoperative course was favorable. Six weeks later, MRI showed complete resolution of the ascites and a 5-cm organized pancreatic collection communicating with the distal main pancreatic duct. This case highlights an unusual occurrence of Salmonella Enteritidis peritonitis complicating pancreatic ascites in the absence of gastrointestinal perforation or documented bacteremia. Sudden clinical deterioration in patients with pancreatic ascites should prompt immediate reassessment for infectious complications and, when indicated, urgent surgical exploration for source control. Definitive management of the pancreatic ductal leak may be deferred in selected patients when the infectious complication has been controlled and clinical evolution is favorable.