Effective Percutaneous Catheter Drainage for a Huge Intra-Abdominal Pancreatic Pseudocyst Accompanied by Splenic Vein Occlusion

Abstract

A 46 year-old, alcoholic man was admitted to our hospital because of fever and abdominal distension. Abdominal computed tomography (CT) revealed a huge pancreatic pseudocyst occupying the abdominal cavity that expanded into the pelvic cavity, which was suspicious for bacterial infection. In addition, there was a 55 mm pseudocyst around the pancreas in the bursa omentalis, which connected with the huge intra-abdominal cyst. Since conservative therapy with drugs was ineffective, we placed 2 drainage catheters percutaneously to the intra-abdominal cystic portion and to the peri-pancreatic cyst in the bursa omentalis. After one month of percutaneous catheter drainage (PCD) and lavage of the cyst, the pseudocyst was decreased in size and finally disappeared without any surgical interventions. The splenic vein had been stenotic on CT scans before the initiation of PCD and was completely occluded on the 45th day after PCD, although the precise onset of occlusion was not determined. However, on the 57th after PCD, CT scans showed the tendency of improvement in patency of the vein and the patient was discharged on the 65th day after PCD. We considered that the occlusion of the splenic vein was caused not only by compression from the huge pseudocyst but also by peri-pancreatic inflammatory changes.FIGURE 1: CT findings before and after the treatment by PCD. (AYD) A huge pancreatic pseudocyst on CT scans on the 8th day after admission. The pseudocyst occupied the abdominal cavity (AYD) and expanded into the pelvic cavity (B), which was suspicious for bacterial infection. The peri-pancreatic pseudocyst in the bursa omentalis (Symbol) connected with the intra-abdominal huge cyst (arrow)(A,C,D). E, CT scans on the 57th day after PCD revealed complete occlusion of the splenic vein (arrow head) partly because of the peri-pancreatic inflammatory changes.SymbolAlthough the effectiveness of PCD for pancreatic pseudocyst is controversial,1,2 PCD seemed to be the most appropriate initial treatment for such a large pseudocyst as was shown in this case, given that the indications for PCD were carefully determined and drainage catheters were properly placed. One of the critical complications of pancreatic pseudocysts is splenic vein occlusion, which might cause left portal hypertension.3 Therefore, it is important to pay attention to the development of splenic vein occlusion even when a pancreatic pseudocyst is decompressed effectively by PCD. We demonstrated the case of a huge pancreatic pseudocyst occupying the abdominal cavity and causing splenic vein occlusion that was treated successfully by PCD without any sequelae.