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Penetrating duodenal ulcer as a cause of acute necrotizing pancreatitis.

687 collection was performed. During the endoscopic procedure, a transmural stent was placed under the gastric cardia. Attempts to insert the catheter near the endoprosthesis and through the stoma to the WOPN were unsuccessful. A fiberoscope inserted into the duodenum revealed a 3-cm peptic ulcer perforation on the posterior wall of the duodenal bulb of the pancreas. An 8.5-Fr nasocystic drain (Wilson-Cook, Limerick, Ireland) was guided through this perforation into the necrotic cavity (FIGURE 1B). A contrast agent administered after the procedure through the filled drain showed the flow of necrotic material via the perforation towards the duodenum, as well as towards the stomach via the transmural stent (FIGURE 1C). A culture of the necrotic content showed Prevotella oralis and Peptostreptococcus; therefore, continous antibiotic therapy (piperacillin and tazobactam) was administered intravenously for 14 days. After 1 week of active transduodenal drainage, the WOPN gradually improved. The nasocystic drain and transgastric stent were removed. However, the 8.5-Fr transmural endoprosthesis (Wilson-Cook) that was inserted into the necrotic area through the peptic ulcer perforation was retained to prevent the recurrence of necrotic collection (FIGURE 1D–F). Three months after active drainage was discontinued, CECT showed complete A 69-year-old woman developed acute necrotizing pancreatitis of unknown etiology. She was admitted to the Department of Gastroenterology and Hepatology, Medical University of Gdansk, because of abdominal cavity pain and fever (39°C) lasting 3 days. Twenty-five days earlier, she underwent passive endoscopic drainage of sterile walled-off pancreatic necrosis (WOPN) at another medical center. Using endoscopic-ultrasonographic guidance, a gastro-pancreatic fistula was made, and a “double-pigtail” 10-Fr stent was inserted into the cavity where the necrotic material was collecting. During her hospitalization, laboratory blood tests showed increased levels of inflammation markers (leukocytosis and elevated C-reactive protein levels). Contrast-enhanced computed tomography (CECT) revealed 2 irregular, well-walled-off fluid collection areas with gas bubbles and heterogeneous content near the pancreas, indicative of tissue elements. The first collection area (size, 32 × 52 × 62 mm) was located between the head and body of the pancreas, whereas the second collection area (size, 75 × 37 × 80 mm) was located near the body and tail of the pancreas (FIGURE 1A). Infection due to the WOPN and inefficient passive endoscopic drainage were observed; therefore, active drainage of the infected necrotic