Vol. 7, Issue 1, Part A (2025)

A 46-year-old female was referred to our hospital with low grade fever, progressive abdominal distension since one month. The patient presented to our hospital with recurrent ascites, despite having undergone multiple diagnostic and therapeutic paracentesis at an outside facility. Imaging revealed a large anterior collection (7 × 21 cm) along with lesser sac and pelvic collections, with severe pancreatic atrophy. Endoscopic ultrasound confirmed chronic pancreatitis with pseudocyst and loculated ascites. Fluid analysis showed neutrophilic predominance (TC:13, 500) but unexpectedly a low amylase (<30) in aspirated collection, suggesting spontaneous bacterial peritonitis (SBP). Subsequent lesser sac aspirate revealed the same. The patient was treated with pigtail drainage of anterior preperitoneal collection, EUS guided CGS of lesser sac collection, pancreatic duct stenting, i.v antibiotics and leading to significant resolution of the collection. Patient previously had multiple admissions for diagnostic and therapeutic tapping of ascitic fluid. This case highlights the diagnostic dilemma of loculated collections mimicking pancreatic fluid collections. Low amylase levels in preperitoneal collections may mislead clinicians, emphasizing the need for comprehensive imaging and fluid analysis to guide management.