S1588 Extra Pancreatic Pseudocyst (EPP) as an Initial Presentation in an Alcoholic Woman With No Previous Medical History

Abstract

Introduction: Pseudocyst of pancreas is the most common complication of Acute and chronic pancreatitis. Pseudocysts can be intrapancreatic, peripancreatic and extra pancreatic. EPP in liver is a rare complication of Acute and chronic pancreatitis and only 26 cases have been reported so far. Here we are presenting a case of extra Pancreatic Pseudocyst located in the gall bladder fossa. Case Description/Methods: A 59-year-old female with history of Chronic alcohol use presented with severe abdominal pain of 10 days duration. The pain was sudden in onset, sharp, constant located diffusely throughout her abdomen but was noted to be worse on the right upper (RUQ), radiating to her lower back and right shoulder. She drinks at least 2 glasses of wine daily for several years. Vital signs are stable on admission. On physical exam, the abdomen was soft, rigid with rebound tenderness in RUQ. Labs showed an elevated C-Reactive Protein 20.6, Sedimentation Rare 123, WBC 18.2, platelets 637, lipase 906. Ultrasound showed hepatic steatosis with complex fluid collection adjacent to the gallbladder in the right hepatic lobe. Computed Tomography scan demonstrated a severe colitis along with 4.8 cm x 3.3 cm complex fluid collection in the gallbladder fossa and an enlarged pancreatic head with loss of adjacent fat planes and tracking of fluid into the mesentery, and a 7 mm fluid collection within the pancreatic head. Patient was started on IV antibiotics along with continuous IV fluids for sepsis and questionable pancreatitis due to fever spikes (102.3F) and Interventional radiology (IR) placed a drain. The appearance of the fluid with elevated enzymes (Fluid Lipase and Amylase: 5104 and 605) was consistent with pancreatitis. MRI/MRCP showed a 2.7 cm fluid collection in the pancreaticoduodenal groove and marked inflammatory changes around hepatic flexure of the colon and a persistent fluid collection posterior to the gallbladder. IR drained collection regional to the liver and gallbladder. Resolution of the fluid collection following drainage was noticed. All cultures were negative, antibiotics were discontinued. Patient improved clinically. Discussion: Most common location for EPP is lesser sac and least common site is Liver. Pathophysiology behind it is inflammatory disruption causing leakage of pancreatic fluid that migrates along hepatogastric, hepatoduodenal or by digesting tissue in the hepatic parenchyma. EPP are important to identify and surgical drainage would be mainstay of treatment to prevent severe complications.Figure 1.: CT scan showing collection in Gall Bladder fossa.