Hemorrhagic Pancreatic Pseudocyst

Abstract

Bleeding from pancreatic pseudocyst is an extremely rare complication, however it is a common finding in patients with history of pancreatitis and alcohol abuse. Pseudoaneurysm complicating pseudocyst is a rare occurrence and is reported in 10% of patients with chronic pancreatitis. 1 We report a 34 year old man with a hemorrhagic pseudocyst due to splenic artery pseudoaneurysm. 34 year old man with ongoing ETOH abuse and history of acute pancreatitis presents with 4-5 days of dark stools and 2 months of left sided abdominal pain. On physical exam, patient appeared comfortable and was hemodynamically stable, but had mild epigastric tenderness. EGD showed submucosal bulging (Image 1 and 2) in fundus/ body that prompted cross sectional imaging. The CT A/P with contrast (Image 3) showed a large mass highly concerning for a hemorrhagic pseudocyst w/ a 1.0 cm hyperdense focus within the supero-lateral portion of the hemorrhagic collection concerning for active extravasation from a suspected pseudo-aneurysm of the splenic artery. Patient was immediately taken for an angiography with IR and no extravasation was noted that afternoon; however, a repeat angiography the next day showed active extravasation of the distal branch of the splenic artery. A coil embolization was performed immediately. Patient was transferred to MICU for further monitoring and remained hemodynamically stable until discharge. While any splanchnic vessel can be source of bleeding, the splenic artery is most commonly involved in pseudo-aneurysm formation. Bleeding should be suspected in patients with a pseudocyst if a) no obvious bleeding source can be found on endoscopy b) sudden drop in hematocrit c) increase in pseudocyst size d) bruit heard on auscultation over pseudocyst. Angiography is the gold standard for examination. Current practice entails contrast enhanced CT, which guides the need for angiography and further embolization or surgery.2 As demonstrated in our case, a high index of suspicion is important in the management of pancreatic pseudocysts as our patient (with history of alcoholism) was hemodynamically stable and having only mild abdominal pain. 1. Bretagne JF, et al. Pseudo aneurysms and bleeding pseudocysts in chronic pancreatitis: radiological findings and contributions to diagnosis in 8 cases. Gastrointest Radiol. 1990. 2. Hsin-Hui Chiu, et al. Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage. The American Journal of Surgery. 2006.1376_A.tif Figure 1: No Caption available.1376_B.tif Figure 2: No Caption available.1376_C.tif Figure 3: No Caption available.