Splenic Involvement of a Pancreatic Pseudocyst Managed With Distal Pancreatectomy and Splenectomy

Abstract

Splenic complications of pancreatitis are rare despite its close proximity to the pancreas.We present a patient with acute on chronic pancreatitis complicated by pancreatic tail pseudocyst,splenic vein thrombosis with gastric fundal varices,and splenic hematoma who underwent a distal pancreatectomy and splenectomy. A 38 year old male with a past medical history of alcohol abuse and prior episodes of acute pancreatitis presented to our hospital with a 5 week history of left sided abdominal pain. On presentation,vital signs were significant for a temperature of 38.1C,otherwise hemodynamically stable.Physical exam was remarkable for icterus and left upper quadrant abdominal tenderness. Laboratory studies were significant for a total bilirubin of 2.2 mg/dl,direct bilirubin of 1.5 mg/dl, aspartate aminotransferase of 190 U/L,alanine aminotransferase of 71 U/L,and alkaline phosphatase of 461 U/L.The complete blood count and basic metabolic panel were unremarkable. Computed tomography of the abdomen and pelvis with intravenous contrast demonstrated a dilated main pancreatic duct communicating into a 7x5 cm cystic structure at pancreatic tail and subcapsular splenic connection communicating with the pancreatic tail collection suggesting a hematoma,measuring 17x7cm.MRI redemonstrated the cystic fluid collection in the pancreatic tail without vascular pseudoaneurysm;irregularity of the distal pancreatic duct concerning for main pancreatic duct disruption and leakage into the pseudocyst;large subcapsular splenic hematoma,& acute splenic vein thrombosis with extensive splenic and gastric collaterals involving the gastric fundus.He underwent ERCP with ventral pancreatic sphincterotomy and placement of 5 Fr x15 cm plastic stent for a single disruption with leak of contrast found in the body/tail junction of the pancreatic duct.The EUS portion of the exam showed an abundance of collateral vessels between the gastric wall & pseudocyst, so axios stent was not placed due to inability to demonstrate safe window.Three days after presentation, patient underwent splenic artery embolization in preparation for a distal pancreatectomy and splenectomy which was ultimately performed 6 days after presentation. Most splenic complications regress spontaneously, however with regard to endoscopic vs.surgical intervention,the location of the pseudocyst,its distance from the gastrointestinal wall,and splenic vein involvement,are factors that will predict what choice should be made.Figure. 5x7: cm cystic structure at the pancreatic tail.