acute obstructive suppurative pancreatic ductitis ( aospd ) is a rare complication of chronic pancreatitis that has been described in only seven previous case reports since 1995 .
aospd is defined as suppuration from the pancreatic duct ; however , in contrast to the pancreatic infections that typically complicate chronic pancreatitis , it is not associated with pancreatic pseudocyst , abscess or necrosis .
a 33-year - old female presented in july 2015 , with complaints of pain in epigastric region and multiple episodes of vomiting .
pain was dull aching and radiating to back associated with multiple episodes of bilious vomiting . on per abdomen examination , there was tenderness in epigastrium and right hypochondrium .
laboratory investigations revealed an elevated total leukocytes count ( 10 000/cumm ) , with normal serum amylase ( 41.9 units / l ) and serum lipase ( 29.4 units / l ) .
, multiple radio - opaque shadows were seen corresponding with distal part of pancreas ( fig .
ultrasonography was suggestive of hyper - echoic and atrophic pancreas with main pancreatic duct dilated upto 1 cm and 6 mm calculus in the main pancreatic duct at the level of pancreatic head . on computed tomography ( ct ) , multiple , conglomerated calcifications
were noted in the head and tail of pancreas and just proximal to ampulla of vater resulting in dilatation of the common bile duct , common hepatic duct and main pancreatic duct ( fig .
2 ) . 
 figure 1:radiograph showing multiple radio - opaque shadows corresponding to the distal part of pancreas . 

intra - operative photograph showing frank pus on opening of pancreatic duct . on august 2015 , patient underwent endoscopic retrograde cholangio - pancreatography ( ercp)-guided stone removal with common bile duct ( cbd ) stent placement at other center .
two months later , patient came back with fever and pain in epigastric region with multiple episodes of bilious vomiting . on examination , there was tenderness all over the abdomen .
patient was taken for exploratory laparotomy . on exploration of pancreas main pancreatic duct aspiration revealed frank pus ( fig .
the presence of a stone was noted at the tail of pancreas , which was crushed and extracted .
longitudinal pancreaticojejunostomy with roux - en - y jejunojejunostomy was done . on microbiological examination of pus
she was started on pancreatic lipase 25 000 iu twice daily for additional 3 months .
chronic pancreatitis is an inflammatory and fibrosing disease of the exocrine pancreas characterized by irreversible morphological changes and permanent loss of function . according to the marseille  rome classification of 1988
, chronic pancreatitis is used to refer to recurrent or persistent abdominal pain that is associated with irreversible and ongoing inflammatory destruction of exocrine parenchyma and , eventually , islets . a new clinical entity termed as aospd
was described by weinman et al . , defining it as a rare complication of chronic pancreatitis with suppuration of the pancreatic duct not associated with pancreatic pseudocyst , abscess or necrosis .
aospd has been described in only seven previous case reports since 1995 . while the pathogenesis of aospd is not completely understood , chronic pancreatitis , prior sphincterotomy , pancreatic stasis secondary to pancreatic duct obstruction and diabetes mellitus
patients undergoing biliary sphincterotomy have a common or shared biliary and pancreatic sphincter ; duodenal contents might also reflux into the pancreatic duct , in effect seeding the pancreatic duct .
if pancreatic duct stones were obstructing the outflow of the duct , a ductal infection could result .
this would be analogous to calculus obstruction of the biliary tree resulting in acute bacterial cholangitis .
the normal pancreas is usually resistant to infection , presumably because of the presence of bacteriostatic and bacteriocidal agents elaborated in pancreatic secretions . a chronically diseased pancreas may be much more susceptible to infection because these same antibacterial agents may be significantly impaired or diminished .
a pancreatic duct contaminated by duodenal reflux and obstructed by intraductal stones , in the setting of chronic pancreatitis , would seem a sufficient setting for the development of acute suppuration of the pancreatic duct .
diabetes mellitus , while not present in our patient , predisposes patients to a variety of uncommon infections and may play an additive role in infection with klebsiella .
this bacterium is usually contracted by oral route and one can only speculate that during previous instrumentation of the ampulla of vater , duodenal contents contaminated with this unusual organism may have refluxed into the pancreatic duct resulting effectively in seeding of the pancreatic juice . however , the presence of bacteria in the pancreatic duct is not by itself sufficient to cause suppuration .
fujimori et al . reported a case of aospd in the setting of peripheral blood stem cell transplantation for acute myeloid leukemia and subsequent chronic leucopoenia .
tajima et al .   described aospd in the setting of pancreatic cancer ; as it can predispose to infection from biliary or pancreatic obstruction .
in all the reported cases the diagnosis of aospd was made on identification of pus in the pancreatic duct on ercp . in our case ,
the diagnosis was made on exploring the main pancreatic duct before performing a pancreaticojejunostomy . in all previous cases , patients complaints resolved post - ercp stent . here , the definite treatment was a longitudinal pancreaticojejunostomy with roux - en - y jejunojejunostomy ( modified puestow procedure ) .
surgery results in opening of the pancreatic capsule , which alleviates interstitial pressure , whereas longitudinal anastomosis ensures full drainage of the whole pancreatic duct length . as aospd is a rare complication of chronic pancreatitis it should be kept in mind while coming across cases with dilated main pancreatic duct and chronic pancreatitis .
once diagnosed , aospd should be treated with prompt intravenous antibiotic treatment with pancreatic duct decompression , which can be achieved either through ercp stenting or surgical decompression specifically longitudinal pancreaticojejunostomy with roux - en - y anastomosis .
surgical management should be preferred as ercp stenting can further lead to biliary reflux into the pancreatic duct after ercp sphincterotomy , which lead to further infection of the pancreatic duct .
however , as only seven cases have been reported since 1995 , there appears to be some other factors contributing to its pathogenesis .
thus , further study into this rare entity shall help provide more information in the near future .
 abstractacute obstructive suppurative pancreatic ductitis ( aospd ) is a rare complication of chronic pancreatitis that has been described in only seven previous case reports since 1995 . 
 we report a case of a 33-year - old female a known case of chronic pancreatitis with computed tomography suggestive of dilated main pancreatic duct with multiple calcifications . on exploration , 
 pancreatic duct aspiration revealed frank pus . 
 pus was drained after opening the pancreatic duct and longitudinal pancreaticojejunostomy was done . 
 patient was relieved of her symptoms after surgery . in conclusion , 
 aospd should be considered in long standing cases of chronic pancreatitis . 
 aospd appears to respond quickly after drainage procedure like longitudinal pancreaticojejunostomy and should be considered the treatment of choice . 