Acute pancreatitis and omental thickening in a patient with Acute-On-Chronic Liver Failure (ACLF) associated with hepatitis B

Acute Pancreatitis (AP) in patients with Acute-On-Chronic Liver Failure (ACLF) is rare and remains poorly understood.The co-occurrence of these conditions poses a significant therapeutic challenge and is associated with high mortality.A 29-year-old male with Hepatitis B Virus (HBV)-related cirrhosis (Child-Pugh C) and spontaneous bacterial peritonitis (SBP) presented with an unexpected ultra-sonographic finding of acute pancreatitis, supported by an elevated serum lipase level of 765 U/L.The patient had a normal body weight, abstained from alcohol, and had no evidence of cholelithiasis or hypertriglyceridemia.Further evaluation with contrast-enhanced abdominal CT revealed omental thickening resembling peritoneal carcinomatosis.He subsequently developed hepatic encephalopathy and multi-organ dysfunction and was classified as having grade III ACLF (AARC score: 12).Various pancreatic toxins can activate trypsinogen into trypsin through colocalization with lysosomes.In addition, upregulation of tumor necrosis factor (TNF) in cirrhosis may directly induce premature trypsinogen activation.The release of trypsin results in autodigestion of acinar cells, followed by activation of digestive and non-digestive enzymes, leading to proteolysis, vascular injury, and fat necrosis.Portal hypertension may exacerbate AP and promote progression to a necrotizing form.Damaged acinar cells release inflammatory mediators that activate macrophages in distant organs, such as the liver and omentum.Extra pancreatic necrosis, activated macrophages, and inflammatory mediators within the omentum may appear as grape-like clusters, mimicking peritoneal carcinomatosis.Histopathological confirmation is required for definitive diagnosis.Cirrhosis progression can induce and exacerbate AP, while AP may precipitate acute decompensation of cirrhosis to ACLF through enzymatic and immunologic mechanisms.Distant organ complications, such as extrapancreatic necrosis, may occur and mimic other conditions, underscoring the complexity of diagnosis and management.