Background  Acute pancreatitis is fraught with a variety of complications, which account for the mortality associated. Our case had a fulminant course, with three rare, near-fatal complications and was successfully managed conservatively. Pleural effusion due to pleuro-pancreatic fistula is uncommon, seen in only 1% cases, of which right-sided effusions are rarer still. Management modalities include conservative, endoscopic, and surgical options. Chylous ascites is an extremely rare complication of pancreatitis and is managed with high protein, low lipid diet, restricted to medium-chain triglycerides (MCTs). Extra-splanchnic venous thrombosis is uncommon in pancreatitis, and isolated renal vein thrombosis is very rare. Case Presentation  A 34-year-old, chronic alcoholic male, presented to the outpatient department (OPD) in a state of shock and respiratory distress. Chest radiograph showed massive right-sided pleural effusion. The pleural fluid was hemorrhagic with markedly elevated amylase levels, and contrast-enhanced computed tomography (CECT) confirmed the presence of a right-sided pleuro-pancreatic fistula. Left renal vein thrombosis was also noted. The patient improved with chest drain, intravenous (IV) octreotide, and anticoagulants. Subsequently, he developed hemorrhagic pancreatic ascites, which later turned chylous. This was managed with dietary modifications. The patient had a prolonged recovery but was finally discharged after 45 days. Conclusion  It is a challenge managing the various complications of acute severe pancreatitis. We describe this case to emphasize maintaining a high sensitivity for timely diagnosis and appropriate addressal of all the complications for better patient outcomes.

Background Abdominal wall hernia is a common surgical entity worldwide with groin hernias having the most common presentation among them. They are a cause of morbidity and mortality if not addressed in time. A variety of surgical methods are available for the repair of hernias. The tension-free repair using synthetic mesh has the least recurrence and is the most accepted. Aim To describe the surgical burden and clinical profile of abdominal wall hernias as well as experiences in their management in a rural setup. Methods This was a retrospective observational study of all the cases of abdominal wall hernias presenting to various surgical divisions of Mahatma Gandhi Institute of Medical Sciences, Sevagram, during a two-year period from December 2011 to November 2013. Relevant details were collected from the hospital information statistics and patient file records and analysis of obtained data was done. Result A total of 910 out of 90,056 surgical outpatients (10.10%) seen during this period had abdominal wall hernias; 816 (89.67%) got operated. A total of 163 (20%) of 816 were operated in an emergency. Groin hernias were the most common 653 (80%), followed by incisional 82 (10%), umbilical and paraumbilical 41 (5%), epigastric 33 (4%), and rarer hernias in 8 (1%). Of 816 operations, 24 (2.9%) had recurrent hernias and 83 (10.17%) were pediatric patients. Male to female ratio was 9:1 in adults and 4:1 in children. The median age among adults was 49 years (range: 14–95 years), and among the pediatric age group, it was 7 years (range: 3 months–14 years). The majority of the adult patients were from a low-income group and presented more than 2 years after symptoms appeared. Comorbid conditions encountered were hypertension in 212 (26%), diabetes in 155 (19%), chronic airway disorders in 449 (55%), cardiac problems in 163 (20%), obesity in 10 (1.2%), and chronic renal failure and liver disorder in 82 (1%). Predisposing factors in the majority of the patients were chronic cough 449 (55%), prostatic problems in 187 (23%), chronic constipation in 163 (20%), previous surgeries in 82 (10%), obesity in 10 (1.2%), and ascites in 9 (0.1%). Hernia surgery was performed laparoscopically in 51 (6.25%) patients. Simultaneous other surgeries were performed in 130 (16%) patients. Mortality occurred in 2 (0.24%) patients operated in emergency, and chief morbidity was due to wound infection in 25 (3%) and chronic pain in 30 (3.9%) patients. Conclusion Abdominal wall hernias are common clinical entities. Although the pattern of presentation and management is similar, the challenges faced in a rural setup are due to ignorance, social inhibitions, and financial restraints, leading to delayed presentations which increase their morbidity and mortality. Health programs and surveys to increase awareness in rural areas as well as cutting down on expenses could help these patients.

Highlights Even high-grade splenic injuries are manageable using interventional radiology with selective splenic artery embolization. Patient co-morbidities and other associated injuries affect the outcomes. Very morbid patients could be salvaged by judiciously executed ICU care and non-invasive procedure undertaken with informed risks.

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