**7. Pancreatic duct leaks and pancreatic fluid collections**

Pancreatic duct disruptions occur in both acute and chronic pancreatitis and in some cases in case of pancreatic trauma. Pancreatic duct leaks can complicate acute pancreatitis as a result of ductal epithelial disruptions by the inflammatory process and in chronic pancreatitis, as a result of ductal obstruction from inflammatory

strictures and intraductal stones [24]. Pancreatic duct leaks may have variable presentations such as pancreatic fluid collections e.g. pseudocysts, pancreatic ascites, external pancreatic fistulas, disconnected duct syndrome among others. Pancreatic fluid collections may also result as a complication of pancreatic necrosis.

Diagnosis may be made using cross-sectional imaging studies such as Computed Tomograpgy (CT), secretin-enhanced MRCP or ultrasonography. Due to the associated risk of causing or worsening pancreatitis, ERCP is not employed for primary diagnostic purposes but rather for therapeutic interventions. EUS-guided Fine Needle Aspiration can be used to obtain pancreatic pseudocyst fluid for analysis for amylase levels, carcino-embryonic antigen (CEA) and cytology to differentiate pseudocyst from cystic neoplasms [24].

Pancreatic duct leaks may be effectively managed by endoscopic trans-papillary pancreatic duct stenting with a stent that bridges the leak diverting pancreatic fluid drainage from the ductal disruption to the duodenum.

Pancreatic pseudocysts occur as complications of acute or chronic pancreatitis and are usually asymptomatic except in a few cases. Pseudocysts and other pancreatic fluid collections can be managed endoscopically with a success rate of 70–97% [23, 25] and complication rate of 5–19% with complications such as hemorrhage and recurrence [26].

Endoscopic transluminal or trans-papillary drainage options with or without ultrasound are effective in draining these cysts and are usually performed 4 to 6 weeks after the acute pancreatitis episode resolves [23, 24]. Pancreatic pseudocysts can be drained via endoscopically created cysto-gastrostomies or cysto-enterostomies with subsequent stent placement. EUS is helpful in identification and preventing trauma to blood vessels during the procedure and also in situations where there is no visible bulge from the cyst in the gastrointestinal lumen. Though less popular recently, pancreatic fluid collections can also be managed with transmural or transpapillary placement of plastic stents [25].
