Conservative Management of a Large, Symptomatic Pancreatic Cyst in a Community Hospital

Abstract

Pancreatic cysts (PC) are increasingly treated using new endoscopic approaches; however, these techniques are not always readily available and may not always be necessary. Our case describes management of a large PC in a community hospital setting with relatively minimal intervention. A 49-year-old woman with a history of type 2 diabetes presented to a community hospital with epigastric pain. She was diagnosed with pancreatitis, with CT evidence of pancreatic necrosis. Her initial hospital course was complicated by respiratory failure and sepsis, which was ultimately managed conservatively at a tertiary center. Two weeks after her initial presentation, she was re-admitted with recurrent fever, abdominal pain and distension. CT revealed findings consistent with a pseudocyst. Due to persistent fever and pain, repeat imaging was done 3 days later which showed that the cyst had increased from 10cm to 15cm. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which confirmed a disrupted pancreatic duct (PD). A 5 fr, 5cm PD stent was placed. The patient initially improved, but again presented with fever, abdominal pain and poor intake by mouth. A repeat CT showed that the cyst had enlarged to 20cm with compression of the stomach. Repeat ERCP was performed, persistent PD leak was confirmed, and a 5fr, 9cm PD stent was placed. She required support with parenteral nutrition and antimicrobials, but was discharged to home several weeks later in stable condition, tolerating a regular diet. Repeat CT done prior to discharge confirmed that the cyst had decreased to 13cm. The stent was removed 6 weeks later. At six-month follow-up, she was doing well and imaging showed complete resolution. Patients with asymptomatic PC can be managed conservatively. Management of symptomatic PC usually requires surgical, percutaneous, or endoscopic intervention. Endoscopic intervention has become first line intervention for PC. The use of cyst gastrostomy has been widely publicized, but use is generally limited to tertiary centers. Moreover, many community hospitals are unwilling to manage complicated pancreatic disease, due in part to concerns about the inability to intervene endoscopically, radiographically or surgically if indicated. Despite a concerning and complicated course, our patient was managed successfully at a community hospital with supportive care and a relatively conservative intervention - PD stent placement - that is generally available.Figure: CT Abdomen After Initial Stent Placement: Cyst at its largest size, 20cm, with compression of stomach.Figure: CT Abdomen Prior to Discharge: Improved size of cyst after 9cm stent placement.