Woman with Epigastric Pain

Abstract

A 67-year-old woman presented to the emergency department with several hours of epigastric pain. She had a history of pancreatitis complicated by a pseudocyst 5 years before. On physical examination, she was afebrile, with a blood pressure of 205/110 mm Hg and pulse rate of 83 beats/min. She had marked tenderness without muscle guarding over the epigastric area. Laboratory investigations revealed a normal hemoglobin level and an elevated lipase level (111 IU/L). Although pancreatitis was suspected, the emergency physician performed point-of-care ultrasonography (Figure 1) and confirmed the diagnosis with a computed tomographic (CT) scan (Figure 2).Figure 2CT image of the abdomen showing a cystic mass (arrowhead) in the pancreatic tail with a hemorrhagic component and contrast extravasation (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pancreatic pseudocyst with intracystic hemorrhage. Emergency transarterial embolization of the posterior pancreatic artery was performed, and she was discharged uneventfully from the hospital. Pancreatic pseudocyst is a common complication of pancreatitis, but intracystic hemorrhage is a rare and potentially life-threatening condition with a mortality rate ranging from 15% to 50%.1Chiang K.C. Chen T.H. Hsu J.T. Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm.World J Gastroenterol. 2014; 20: 16132-16137Crossref PubMed Scopus (28) Google Scholar Clinical manifestations include abdominal pain, anemia, and melena.2Chiu H.H. Chen C.M. Wang K.C. et al.Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage.Am J Surg. 2006; 192: 87-88Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Delayed diagnosis may lead to complications such as rupture of the hemorrhagic pseudocyst, which can cause hemoperitoneum and shock. Angiographic embolization of the culprit artery is the mainstay of management,3Gambiez L.P. Ernst O.J. Merlier O.A. et al.Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis.Arch Surg. 1997; 132: 1016-1021Crossref PubMed Scopus (115) Google Scholar with surgical intervention reserved for refractory cases.