A Case of Hemorrhagic Pancreatic Pseudocyst as a Complication of Chronic Pancreatitis

Abstract

Chronic pancreatitis can be associated with a variety of complications the most common being the formation of a pseudocyst. Hemorrhagic complications such as bleeding into a pseudocyst or from a pseudoaneurysm are rare but are associated with a significant mortality and therefore merit consideration in the right clinical scenario. A 54 year old woman with a history of chronic pancreatitis with pseudocyst and alcoholic cirrhosis presented to the emergency department with acute right upper quadrant abdominal pain. Initial work up included an ultrasound, which revealed cholelithiasis without any signs of cholecystitis. Diagnostic paracentesis was negative for an intraperitoneal infection. During the hospitalization, the patient was noted to have a gradually downtrending hemoglobin with reported dark stools. Upper endoscopy was performed, revealing a large submucosal bulging mass in the body of the stomach with a small overlying superficial ulcer and stigmata of recent bleeding. A hemostatic clip was placed over the ulcer. On endosonographic examination, a heterogenous mass of about 4 cm was seen abutting the posterior wall of the stomach. Computed tomography revealed the pancreatic pseudocyst which had increased in size from 4.1x3.2 cm a year ago to 7.0x5.4 cm with evidence of active bleeding into the cyst. An emergent splenic arteriogram was performed which showed no active bleeding and no pseudoaneurysm. A prophylactic coil embolization of the distal left splenic artery was performed. Hemoglobin was stable after embolization. Hemorrhagic pancreatic pseudocysts are rare late complications of chronic pancreatitis occurring either from a pseudoaneurysm or venous and capillary bleeding, the latter often escaping angiographic detection. In a retrospective review of 1,910 patients who had undergone radiologic evaluation of pancreatitis, 1.3% were found to have hemorrhagic complications. Hemorrhagic pseudocysts accounted for 19.5% of these complications. Common treatment options include arterial embolization or surgical intervention with arterial ligation and resection. However, the latter is reserved for unstable patients or for those in whom the culprit vessel is not visualized angiographically or embolization cannot be performed. Hemorrhagic complications are an important consideration in the patient with chronic pancreatitis presenting with unexplained abdominal pain or bleeding.Figure 1Figure 2Figure 3