Pancreatic Pseudocyst: How Large Can it Get?

Abstract

Pancreatic pseudocysts are a relatively common complication of pancreatitis and chronic alcoholism. Giant pancreatic pseudocyst is a term traditionally used when the pesudocyst is greater than 10 cm in size. However, pseudocysts larger than 20 cm have been rarely reported. We present a case of a giant pancreatic pseudocyst in a patient with history of recurrent necrotizing pancreatitis. 68-year-old male with a history of heavy alcohol abuse presented with acute abdominal pain and vomiting secondary to acute pancreatitis. The initial CT of the abdomen showed acute necrotizing pancreatitis with no loculated peripancreatic fluid collection and cholelithiasis. Patient was initially managed conservatively with no significant improvement. Repeat imaging revealed a large pancreatic pseudocyst measuring 20x12x10 cm (estimated 2400 cc of fluid) on the CT. Patient underwent ERCP with balloon extraction for cholidocholithiasis and stent placement. Subsequently, he became altered and septic. Repeat CT abdomen showed marked interval increase in the size of the pancreatic pseudocyst; 28x25x13 cm (estimated 7000 cc of fluid) [Figure 1 and 2]. Percutaneous CT-guided cyst drainage was performed and Enterococcus faecalis was isolated from the pancreatic fluid. In addition to IV antibiotics, the patient underwent laparotomy with pancreatic necrosectomy, debridement of the pseudocyst and cholecystectomy. Patient did well postoperatively and was discharged with outpatient follow-up. Pancreatic pseudocysts continue to be a diagnostic and therapeutic challenge to gastroenterologists, surgeons and radiologists. Treatment falls into one of two categories: observation and intervention. The most significant factors affecting treatment decisions are maturity, size and location. Bozeman et al., reported the largest pseudocyst in literature, corresponding approximately to 9.5 liters in size. To our knowledge, this is the second largest pseudocyst reported in literature with an estimated size of 7 liters, managed successfully using a multidisciplinary approach.Figure: Sagittal view of the CT Abdomen and Pelvis showing Giant Pancreatic Pseudocyst.Figure: Coronal view of the CT Abdomen and Pelvis showing Giant Pancreatic Pseudocyst.