Directional Patterns in Ruptured Pancreatic Fluid Collections: A Ten-Patient Case Series and Proposed Framework for Management.

BACKGROUND: Rupture of pancreatic fluid collections (PFC) is a rare but high-stakes complication of necrotizing pancreatitis, and its clinical trajectory varies markedly with the anatomical direction of rupture; a directional framework linking rupture pattern to expected clinical course and management is currently lacking. AIMS: To characterize the spectrum of anatomical rupture patterns in patients with PFC and to propose a practical framework for anticipating clinical course and guiding management. METHODS: We retrospectively reviewed ten patients with confirmed PFC rupture at a tertiary center, evaluating presentation, imaging, multidisciplinary intervention, and outcome. RESULTS: All patients were male. Five directional patterns emerged: duodenal, colonic, biliary, thoracic, and vascular-portal, each with a distinct clinical signature and prognosis. Duodenal rupture generally produced favorable spontaneous decompression; colonic involvement was associated with inflammatory erosion, pseudoaneurysm formation, and the majority of adverse outcomes in this series; biliary communication required combined endoscopic, radiological, and surgical decompression; thoracic extension reflected underlying pancreatic ductal disruption; and vascular-portal rupture, a previously underdescribed pattern, produced portal vein thrombosis, portal biliopathy, and fatal sepsis. Management drew on tailored combinations of endoscopic, radiological, endovascular, and surgical techniques. CONCLUSIONS: We propose a direction-based framework to help anticipate clinical course and guide management of this unpredictable complication.