Spontaneous Hemorrhagic Rupture of Pancreatic Pseudocyst

Abstract

Introduction: Pancreatic pseudocysts are commonly seen complicating acute pancreatitis with a reported prevalence of 6-18.5 % prevalence and in cases of chronic pancreatitis 20 to 40%. Most resolve spontaneously 8 to 70% and rarely presents as an emergent condition. We present interesting cases of spontaneous rupture of pancreatic pseudocyst into the peritoneal cavity presented with sepsis due and hemorrhage into the spleen. Case Description: A 56 year old male with a history of atrial fibrillation and GERD presented with epigastric abdominal pain radiating to the back for 1 month associated with 20 lbs unintentional weight loss. On admission, Vitals were WNL. Labs showed lipase 230 U/L, amylase 112 U/L, and lactate 0.7mmol/L, wbc 7.0 and hgb 15.2 g/dl, triglycerides were 189 mg/d and normal CA-19 level. Patient was recently diagnosed with acute pancreatitis. CT scan of the abdomen showed acute on chronic pancreatitis and a 2. 4.5 x 4.4 x 2.8 cm cystic lesion between the tail of pancreas and splenic hilum. US abdomen showed normal gallbladder with no evidence of biliary ductal dilatation. MRCP/MRI of abdomen showed 4.3 cm walled off, possibly hemorrhagic fluid collection, between the spleen and the pancreas. Patient was managed conservatively and discharged home. Patient presented to the ER 3 days after discharge with worsening abdominal pain and sepsis. Physical exam was significant for epigastric and left upper quadrant tenderness without guarding or rebound. Labs showed lactate 3.4 mmol/L, wbc 11.3, hgb of 12.1 and lipase 600. Repeat CT scan showed rupture of the hemorrhagic pancreatic cyst with possible extravasation and splenic infarct. Repeat MRCP/MRIconfirmed CT findings. Surgical intervention was not done due to acute hypoxic respiratory failure and hemodynamic instability therefore, CT guided percutaneous drain was placed. Patient stablized and was discharge home in stable condition with plans for outpatient follow up with surgery. Discussion: Spontaneous pseduocyst ruptured into the peritoneal cavity is a rare life threatening complication requiring immediate surgical intervention. Hemorrhage into the pancreatic pseudocyst is a rare complication with incidence of 10-30% with a high mortality rate (40%). Bleeding most commonly involves splenic artery (30—50%), followed by the gastroduodenal artery (17%) and pancreaticoduodenal arteries (11%). Management is done via splenic artery embolization and ultrasound guided drainage of cyst.1356_A.tif Figure 1: Computed tomography (CT) abdomen showed 4.5 x 4.4 x 2.8 cm cystic lesion between the tail of the pancreas and splenic hilum [Arrow]. Figure 1-B: Magnetic resonance cholangiopancreatography (MRCP) abdomen showed 4.3 cm walled off, possibly hemorrhagic fluid collection, between the spleen and the pancreas [Arrow].1356_B.tif Figure 2: Repeat CT scan showed rupture of the hemorrhagic pancreatic cyst with possible extravasation and enlarged spleen with perisplenic and subcapsular blood represent splenic infarcts [Arrow]. Figure 2 B-C: Repeat MRCP confirmed CT finding [Arrow].