1444 Spontaneous Asymptomatic Intraperitoneal Rupture of a Pancreatic Pseudocyst Prior to Attempted Endoscopic Drainage

Abstract

INTRODUCTION: Pancreatic pseudocysts are inflammatory fluid collections occurring after an episode of acute pancreatitis. Drainage of large pseudocysts is indicated in symptomatic patients at least 4 weeks after an acute episode in order for encapsulation. Prior to stent placement, some advocate for contrast-enhanced imaging to evaluate for a pseudoaneurysm formation. We present a case of symptomatic patient who was scheduled for cystgastrostomy but was found to have had spontaneous intraperitoneal rupture of her pseudocyst, leaving her symptom free. CASE DESCRIPTION/METHODS: A 63-year-old female smoker with a history of ileal Crohn's disease in clinical remission, chronic pancreatitis as well as cholelithiasis was admitted of progressive epigastric and right upper quadrant pain, early satiety, nausea and weight loss three months following an episode of acute pancreatitis. CT performed during hospitalization demonstrated a 15 × 10 × 9 cm pseudocyst in the tail of the pancreas leading to gastric compression, having grown from 4.9 × 5.1 × 2.8 cm within a week of her index presentation. The patient was discharged with close follow up and was evaluated with physical exam within 5 days, at which time endoscopic cystgastrostomy was scheduled for early in the next week. She completed an abdominal CT scan the morning of her procedure noting that over the weekend, her symptoms had substantially improved. Her CT demonstrated a 95% reduction in cyst volume with new perihepatic ascites but she remained clinical asymptomatic. Her procedure was canceled and she was subsequently underwent a cholecystectomy. DISCUSSION: Size alone does not mandate drainage, though larger cysts are more likely to be symptomatic, making treatment indicated. Though guidelines regarding the management of pseudocysts recommend peri-procedural imaging prior to drainage, there is variability in clinical practice. In our case, given the high pre-test probability for pseudocyst (and not a cystic neoplasm), imaging was obtained to rule out a pseudoaneurysm in an effort to reduce a risk of bleeding. Instead, it showed a spontaneous rupture of the pseudocyst, which occurs in <3% of cases, with theoretical mechanisms including minor abdominal trauma, increased intra-abdominal pressure or cyst wall digestion by proteolytic enzymes. Case reports of spontaneous rupture into the stomach and portal vein have been reported. Unlike prior cases of intraperitoneal rupture, our patient remained asymptomatic without evidence of peritonitis.