3037 Spontaneous Cystgastrostomy From Pancreatic Pseudocyst Erosion Into Gastric Wall Resulting in Gastrointestinal Hemorrhage

Abstract

INTRODUCTION: Pancreatic pseudocysts are a common complication of pancreatitis. Spontaneous erosion of a pseudocyst into adjacent organs is rare, manifesting in a variety of clinical symptoms and presentations. We present a case of spontaneous fistulization of a pancreatic pseudocyst into the stomach resulting in life-threatening bleeding. CASE DESCRIPTION/METHODS: A 60-year-old gentleman with history of type 2 diabetes mellitus, hypertension and chronic pancreatitis with known pancreatic pseudocyst presented with multiple episodes of melena associated with fatigue, weakness and epigastric pain aggravated by food intake. He denied history of peptic ulcer disease but admitted to chronic NSAID use. Physical examination revealed a pale patient with mild generalized abdominal tenderness without signs of peritonitis. Melenic stools were noted on digital rectal exam. Labs were significant for critical normocytic anemia with Hgb 6.3 g/dL. CT scan of abdomen and pelvis showed an 11.7 × 9 cm lesion in the pancreatic body with calcified rim communicating with gastric antrum. Gastrograffin swallow showed contrast transfer from stomach into the pseudocyst. A CT-Angiogram of the abdomen and pelvis failed to reveal a source of bleeding or peripancreatic pseudoaneurysms. Patient underwent EGD which showed 1 centimeter antral fistula-opening representing a spontaneous cystogastric fistula. No ulcers were found. The patient eventually underwent surgical excision of pancreatic pseudocyst, antrectomy and Billroth-II reconstruction. DISCUSSION: Pseudocysts complicate 20-40% of chronic pancreatitis. They can cause pain, bowel obstruction, infection, or hemorrhage. Treatment is indicated when cysts become symptomatic or grow beyond 5 cm. However, pseudocysts often resolve by spontaneous drainage into the pancreatic ductal system. Rarely, they can rupture into the peritoneal cavity or erode into nearby hollow organs. Bleeding can be the result of pseudocyst erosion into nearby vessels or rupture of nearby pseudoaneurysms. While involvement of gastroduodenal, splenic, hepatic and inferior pancreaticoduodenal arteries has been reported, none of these sources could be identified in this case. Treatment can take the form of direct embolization or surgical hemostasis. In summary, we have presented a case of pancreatic pseudocyst with spontaneous cystogastric fistula formation accompanied by massive upper GI bleeding eventually treated by surgical excision and Billroth-II reconstruction.