Hemorrhagic Pancreatic Pseudocyst Research Articles

A LATE COMPLICATION OF BLUNT TRAUMA IN A CHILD: HEMORRHAGIC PANCREATIC PSEUDOCYST

Trauma is the most important cause of morbidity and mortality in the pediatric population. Pancreatic injury is relatively rare but has high morbidity and mortality when the diagnosis is delayed. However, diagnosis of pancreatic trauma is difficult. Ultrasound is limited for diagnosing pancreatic injury. Magnetic resonance imaging (MRI) is very useful for detecting direct and secondary signs of pancreatic injury and its complications such as abscess, fistula, pancreatitis, and pseudocyst. We presented a 10-year-old boy with a hemorrhagic pancreatic pseudocyst due to blunt trauma that happened a week ago. His laboratory findings showed elevated serum amylase and lipase levels. In abdominal ultrasonography, bilobular thick-walled fluid collections in the pancreatic parenchyma and peripancreatic location were observed. MRI showed hemorrhagic pseudocysts in the pancreas and pancreatic duct injury. The pseudocysts were treated by cysto-gastrostomy. Children should be carefully evaluated for pancreatic injury and late complications such as hemorrhagic pancreatic pseudocyst to reduce mortality after blunt trauma.

S3342 Hemorrhagic Pancreatic Pseudocyst Managed With Endoscopic Cystogastrostomy With Great Outcome

S3342 Hemorrhagic Pancreatic Pseudocyst Managed With Endoscopic Cystogastrostomy With Great Outcome

S1675 Blame It on the Bamboo Stump: A Pancreatic Ductal Disruption Successfully Managed With Two-Step Endoscopic Therapy

Introduction: Non-penetrating, isolated pancreatic injuries are rare, and the management is not well-established and challenging. Most injuries are managed by surgery, but recently several case reports discuss endoscopic therapy for treatment of main pancreatic duct disruption. We report a case of pancreatic injury from falling on a bamboo stump with complete pancreatic ductal disruption and complete pancreas divisum with a dominant dorsal duct that was successfully nonoperatively managed through endoscopic therapy. Case Description/Methods: An 18-year-old male transferred for worsening abdominal pain from a grade IV pancreatic injury complicated by pancreatic ascites and massive pancreatic fluid collections (PFCs) sustained a month prior after a non-penetrating fall onto a bamboo rod in the Caribbean. He had failed conservative therapy and 2 attempts with ERCP for pancreatic duct (PD) stent placement. CT A/P and MRCP showed a 13cm cyst consistent with hemorrhagic pancreatic pseudocyst (Figure A-B). Labs showed leukocytosis, elevated lipase and LFTs, but he was hemodynamically stable. US-guided paracentesis drained 250mL of fluid consistent with pancreatic ascites. To allow for pancreatic edema reduction, we elected for a 2-step procedure with separate EUS and ERCP. EUS showed multiple PFCs s/P endoscopic cyst-gastrostomy with Axios stent (Figure C-D). Repeat CT A/P showed decrease in size of the PFCs (Figure E). He was discharged and returned in one week for ERCP that revealed a surprising complete pancreas divisum and total disrupted main dorsal PD, which was endoscopically treated with sphincterotomy of the minor papilla and a long PD stent across the disruption (Figure F-H). The Axios stent was removed a week later, and 4 weeks later we successfully removed the PD stents from both the major and minor papillae. He made an uneventful recovery and remains well. Discussion: Pancreatic disruption syndrome or Disconnected Pancreatic Duct Syndrome (DPDS) is an interruption of pancreatic duct continuity, usually from necrotizing pancreatitis, but can occur with blunt or penetrating abdominal injury, as in our patient. Endoscopic management is a minimally invasive option for DPDS and pancreatic ascites. Our patient had severe pancreatic injury managed using 2-stage endoscopic therapy, demonstrating a successful treatment strategy for pancreatic injury with total main DPDS. Further studies are required regarding the selection of patients, safety, and long-term outcomes.Figure 1.: Image A: CT A/P (coronal) demonstrating edematous pancreas with significant peripancreatic fat stranding, with a peripherally enhancing hypodense fluid collection near the body and tail of the pancreas measuring approximately 4.0 x 4.8 x 13 cm in the maximum AP, RL and SI dimensions (red arrow). Image B: MRCP (coronal) Abutting the pancreatic body is a multilobulated rim-enhancing complex fluid collection that extends from the level of the diaphragmatic hiatus to just above the level of the aortoiliac bifurcation and measures 6.8 x 9.7 x 19.1 cm (AP by TR by SI, red arrow). Image C-D: EUS demonstrating large pancreatic fluid collection (PFC, left) and s/P Axios cyst-gastrostomy (right). Image E: CT A/P (coronal) demonstrating cyst-gastrostomy placement with interval decrease in PFC. Image F-H: Pancreatogram showed extravastion of contrast material at the junction of proximal 2/3 and distal1/3 of the dorsal PD c/w disrupted dorsal PD (Complete Pancreas divisum, left). Placement of a 5 Fr 9 cm Zimmon PD stent with pigtail crossing the disruption at the minor papilla (center). Pancreatogram showing no extravasation of contrast material s/P PD stent placement.

Hemorrhagic Pancreatic Pseudocyst that was Difficult to Diagnose: A Case Report

Hemorrhagic Pancreatic Pseudocyst that was Difficult to Diagnose: A Case Report

1257 Pancreatic Pseudocyst-Portal Vein Fistula: A Rare Life-Threatening Complication of Pancreatitis

INTRODUCTION: Pancreatitis is an acute inflammatory process that can results in activation of systemic inflammatory cascade. The pancreas is encased by vasculature which can be directly and indirectly affected. The aim of this case is to provide insight into a rare complication of pancreatitis. CASE DESCRIPTION/METHODS: 35-year-old male with history of alcohol abuse presented to the emergency room with three days of severe epigastric pain. Denied symptoms of overt gastrointestinal bleeding. On admission, vital signs were temperature of 99.2°F, heart rate 115 beats/min, blood pressure of 120/72 mmHg. Initial laboratory evaluation demonstrated hemoglobin of 6.6 g/dL, lipase of 1,910 U/L, alanine transaminase 152 U/L and aspartate transaminase 167 U/L, alkaline phosphatase 681 U/L and direct hyperbilirubinemia 9.2 mg/dL. A computed tomography (CT) of the abdomen showed a large well-circumscribed cystic lesion with hypodense fluid in the peripancreatic C-loop with linear hyperdensity in the center, suggestive of a clot, and with direct communication to a dilated non-opacifying portal vein along with cavernous transformation. These findings were suggestive of a hemorrhagic pancreatic pseudocyst with fistulization of the main portal vein and portal vein thrombosis. The cystic lesion was compressing the common bile duct, measuring 1.1 cm, leading to hyperbilirubinemia. Portovenography did not show active opacification of the cystic lesion and, therefore, the cyst was percutaneously aspirated and 25 cc of light brown fluid removed. Fluid analysis revealed an amylase of 10,196 U/L. Given persistent hyperbilirubinemia, patient was taken for ERCP with biliary stent placement resulting in resolution of jaundice. His clinical course was further complicated by development of ascites and secondary peritonitis which was managed with antibiotics. DISCUSSION: Pancreatic pseudocyst with portal vein fistulization is an extremely rare complication of pancreatitis. The proposed mechanism of fistulization is believed to be due to high pancreatic enzyme contents of the pseudocyst eroding into adjacent structure. The release of digestive enzymes into a patent portal vein may directly cause intravascular thrombosis. Alternatively, it is hypothesized that fistulization usually occurs after portal vein thrombosis. No clear consensus exists on management with high mortality and morbidity secondary to hemorrhage, septic shock, and lipolysis. Our patient improved with conservative management of the pseudocyst with a decrease in cyst size.

A Case of a Hemorrhagic Pancreatic Pseudocyst

A Case of a Hemorrhagic Pancreatic Pseudocyst

Hemorrhagic Pancreatic Pseudocyst

Bleeding from pancreatic pseudocyst is an extremely rare complication, however it is a common finding in patients with history of pancreatitis and alcohol abuse. Pseudoaneurysm complicating pseudocyst is a rare occurrence and is reported in 10% of patients with chronic pancreatitis. 1 We report a 34 year old man with a hemorrhagic pseudocyst due to splenic artery pseudoaneurysm. 34 year old man with ongoing ETOH abuse and history of acute pancreatitis presents with 4-5 days of dark stools and 2 months of left sided abdominal pain. On physical exam, patient appeared comfortable and was hemodynamically stable, but had mild epigastric tenderness. EGD showed submucosal bulging (Image 1 and 2) in fundus/ body that prompted cross sectional imaging. The CT A/P with contrast (Image 3) showed a large mass highly concerning for a hemorrhagic pseudocyst w/ a 1.0 cm hyperdense focus within the supero-lateral portion of the hemorrhagic collection concerning for active extravasation from a suspected pseudo-aneurysm of the splenic artery. Patient was immediately taken for an angiography with IR and no extravasation was noted that afternoon; however, a repeat angiography the next day showed active extravasation of the distal branch of the splenic artery. A coil embolization was performed immediately. Patient was transferred to MICU for further monitoring and remained hemodynamically stable until discharge. While any splanchnic vessel can be source of bleeding, the splenic artery is most commonly involved in pseudo-aneurysm formation. Bleeding should be suspected in patients with a pseudocyst if a) no obvious bleeding source can be found on endoscopy b) sudden drop in hematocrit c) increase in pseudocyst size d) bruit heard on auscultation over pseudocyst. Angiography is the gold standard for examination. Current practice entails contrast enhanced CT, which guides the need for angiography and further embolization or surgery.2 As demonstrated in our case, a high index of suspicion is important in the management of pancreatic pseudocysts as our patient (with history of alcoholism) was hemodynamically stable and having only mild abdominal pain. 1. Bretagne JF, et al. Pseudo aneurysms and bleeding pseudocysts in chronic pancreatitis: radiological findings and contributions to diagnosis in 8 cases. Gastrointest Radiol. 1990. 2. Hsin-Hui Chiu, et al. Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage. The American Journal of Surgery. 2006.1376_A.tif Figure 1: No Caption available.1376_B.tif Figure 2: No Caption available.1376_C.tif Figure 3: No Caption available.

Utility of Endoscopic Ultrasound and Lumen-Apposing Metal Stent in the Management of Hemorrhagic Pancreatic Fluid Collection and Hemosuccus Pancreaticus

Hemosuccus pancreaticus is a rare cause of gastrointestinal bleed and refers to the bleeding from the pancreatic duct into the gastrointestinal tract. Hemorrhage occurs when a pseudocyst or a tumor erodes into a vessel typically a pseudoaneurysm forming a direct communication between the pancreatic duct and the vessel. It is well established that endoscopic drainage of a hemorrhagic pancreatic pseudocyst is usually contraindicated. We report a challenging case of hemosuccus pancreaticus complicated by symptomatic hemorrhagic pancreatic pseudocyst successfully drained by Endoscopic ultrasound (EUS) guided cystogastrostomy using Lumen Apposing Metal Stent (LAMS). A 52 year old man with past medical history of HIV on antiretroviral therapy, hypertension, and diabetes mellitus presented with severe epigastric pain, vomiting and melena for 3 days. Two months prior, he was treated for an episode of acute pancreatitis complicated by splenic vein thrombosis treated with Warfarin. On admission he was noted to be tachycardic. Physical exam was significant for epigastric tenderness and melena. Laboratory studies revealed a high prothrombin time (>40 sec), hemoglobin level of 6.6 g/dl compared to his baseline of 11.6 and lipase of 560 U/L. Computed tomography (CT) of abdomen showed a 15.4 × 10.2 × 17.9 cm pancreatic pseudocyst with heterogeneous high density material consistent with hemorrhage (fig1). CT angiography of the abdomen confirmed these findings without evidence of pseudoaneurysm or active extravasation. The patient received adequate resuscitation. Endoscopic evaluation revealed bleeding from the pancreatic duct and fresh blood in the second portion of the duodenum (fig 2). The Hemorrhagic pseudocyst was successfully drained by EUS-guided endoscopic cystogastrostomy using LAMS. A total of 1500cc of clotted blood drained from the stent (Fig 3). Hemorrhagic pseudocyst of the pancreas carries a very high mortality rate reaching 40%. It is crucial to first identify the presence of a pseudoaneurysm in patients with pancreatic pseudocyst and unexplained gastrointestinal hemorrhage, drop in hemoglobin or expansion of the cyst size. Unless embolization is performed first, Endoscopic draining of a hemorrhagic pancreatic pseudocyst is usually contraindicated. This case highlights the practicability of using Endoscopic draining of a pancreatic pseudocyst using LAMS in the setting of pseudocyst hemorrhage.Figure: (A&B) Endoscopic images post LAMS stent placement showing large amount of dark brown bloody material draining from the stent which represents hemorrhagic pseudocyst (C&D) Repeat CT abdomen images showing the stent in place and a significant decrease in size of the pancreatic pseudocyst.Figure: Coronal and axial view of abdominal CT scan showing a 15.4 × 10.2 × 17.9 cm pancreatic pseudocyst with heterogeneous high density material.Figure: (A&B) Endoscopic images showing blood in the duodenum and blood tinged pancreatic secretions originating from the papilla (C&D) Endoscopic Ultrasound images showing a 15 cm pancreatic cyst with echogenic material and debris.

長期経過観察中の膵仮性囊胞に囊胞内出血を来し膵癌の併存がみられた1例

長期経過観察中の膵仮性囊胞に囊胞内出血を来し膵癌の併存がみられた1例

横行結腸と瘻孔を形成した膵仮性嚢胞内出血の1例

症例は40歳，男性．主訴は血便．30歳よりアルコール性慢性膵炎の急性増悪を繰り返していた．4カ月前に膵仮性嚢胞内出血を指摘され，手術予定であった．1週間前から血便を認め，当日朝に多量の下血を認め緊急入院となった．入院時，血圧は98/65mmHg，血液検査で軽度貧血を認めた．造影CTでは膵尾部に50mm大の仮性嚢胞を認め，嚢胞内部に血腫を認めた．また，嚢胞と横行結腸の瘻孔形成が疑われ，横行結腸穿通を伴う膵仮性嚢胞内出血が血便の原因であると疑った．出血が持続するため，同日緊急血管造影検査を施行した．脾動脈下極枝に仮性動脈瘤を認め，同部位のコイル塞栓術を施行した．以後は血便なく経過した．再出血，嚢胞結腸瘻による感染等を考慮し，膵体尾部切除術および左半結腸切除術を施行した．本症例のように消化管出血を伴う膵仮性嚢胞結腸瘻は稀であり，若干の文献的考察を加えて報告する．

A Case of Hemorrhagic Pancreatic Pseudocyst as a Complication of Chronic Pancreatitis

Chronic pancreatitis can be associated with a variety of complications the most common being the formation of a pseudocyst. Hemorrhagic complications such as bleeding into a pseudocyst or from a pseudoaneurysm are rare but are associated with a significant mortality and therefore merit consideration in the right clinical scenario. A 54 year old woman with a history of chronic pancreatitis with pseudocyst and alcoholic cirrhosis presented to the emergency department with acute right upper quadrant abdominal pain. Initial work up included an ultrasound, which revealed cholelithiasis without any signs of cholecystitis. Diagnostic paracentesis was negative for an intraperitoneal infection. During the hospitalization, the patient was noted to have a gradually downtrending hemoglobin with reported dark stools. Upper endoscopy was performed, revealing a large submucosal bulging mass in the body of the stomach with a small overlying superficial ulcer and stigmata of recent bleeding. A hemostatic clip was placed over the ulcer. On endosonographic examination, a heterogenous mass of about 4 cm was seen abutting the posterior wall of the stomach. Computed tomography revealed the pancreatic pseudocyst which had increased in size from 4.1x3.2 cm a year ago to 7.0x5.4 cm with evidence of active bleeding into the cyst. An emergent splenic arteriogram was performed which showed no active bleeding and no pseudoaneurysm. A prophylactic coil embolization of the distal left splenic artery was performed. Hemoglobin was stable after embolization. Hemorrhagic pancreatic pseudocysts are rare late complications of chronic pancreatitis occurring either from a pseudoaneurysm or venous and capillary bleeding, the latter often escaping angiographic detection. In a retrospective review of 1,910 patients who had undergone radiologic evaluation of pancreatitis, 1.3% were found to have hemorrhagic complications. Hemorrhagic pseudocysts accounted for 19.5% of these complications. Common treatment options include arterial embolization or surgical intervention with arterial ligation and resection. However, the latter is reserved for unstable patients or for those in whom the culprit vessel is not visualized angiographically or embolization cannot be performed. Hemorrhagic complications are an important consideration in the patient with chronic pancreatitis presenting with unexplained abdominal pain or bleeding.Figure 1Figure 2Figure 3

Endoscopic Visualization of a Large Gastric Intramural Hematoma Secondary to a Ruptured Hemorrhagic Pancreatic Pseudocyst: A Case Report

Endoscopic Visualization of a Large Gastric Intramural Hematoma Secondary to a Ruptured Hemorrhagic Pancreatic Pseudocyst: A Case Report

Treatment of Hemorrhagic Pancreatic Pseudocyst by Selective Embolization of the Splenic Artery

Treatment of Hemorrhagic Pancreatic Pseudocyst by Selective Embolization of the Splenic Artery

Bedside Endoscopic Ultrasound in Critically Ill patients

Background. The aim of this study was to evaluate the role and impact of EUS in the management of critically ill patients. Methods. We retrospectively identified all patients at our institution over a 68-month period in whom bedside inpatient EUS was performed. EUS was considered to have a significant impact if a new diagnosis was established and/or the findings altered subsequent clinical management. Results. Fifteen patients (9 male; mean age 58 ± 15 years) underwent bedside EUS without complications. EUS-FNA (median 4 passes; range 2–7) performed in 12 (80%) demonstrated a malignant mediastinal mass/lymph node (5), pancreatic abscess (1), excluded a pelvic abscess (1), established enlarged gastric folds as benign (1) and excluded malignancy in enlarged mediastinal (1) and porta hepatis adenopathy (1). In two patients, EUS-FNA failed to diagnose mediastinal histoplasmosis (1) and a hemorrhagic pancreatic pseudocyst (1). In three diagnostic exams without FNA, EUS correctly excluded choledocholithaisis (n = 1) and cholangiocarcinoma (1), and found gastric varices successfully thrombosed after previous cyanoacrylate injection (1). EUS was considered to have an impact in 13/15 (87%) patients. Conclusions. In this series, bedside EUS in critically ill patients was technically feasible, safe and had a major impact on the majority of patients.

A Rare Case of Hemorrhagic Pancreatic Pseudocyst Secondary to Arc of Riolan Pseudoaneurysm

Purpose: Hemorrhagic complications of chronic pancreatitis can become quickly life-threatening. While uncommon, ruptured pseudoaneurysms are the most rapidly fatal, and typically involve the splenic artery, gastroduodenal artery or pancreaticoduodenal artery. We report a rare case of arc of Riolan pseudoaneurysm rupture resulting in hemorrhagic conversion of a chronic pancreatic pseudocyst with concomitant GI bleed. A 59 year old male with a past medical history of alcoholic chronic pancreatitis, chronic pancreatic pseudocysts, and coronary artery disease presented to our hospital with one day duration of hematemesis and hematochezia. His initial hemoglobin was 12.2 gm/dl, which subsequently dropped to 9.2 gm/dl over 24 hours. An upper endoscopy showed a greater gastric curvature crater oozing dark red blood. Aggressive irrigation of the area showed no obvious source amenable to endoscopic treatment. Given the patient's history of chronic pancreatic pseudocyst, a post-endoscopy contrast-enhanced CT scan revealed active hemorrhage into a known chronic pancreatic tail pseudocyst eroding into the adjacent stomach, secondary to an arc of Riolan pseudoaneurysm. The patient subsequently underwent angiographic evaluation and transcatheter embolization of the arc of Riolan pseudoaneurysm, utilizing metallic coils and Gelfoam. Post-embolization angiography showed pseudoaneurysm exclusion and lack of active contrast extravasation. The patient remained hemodynamically stable for 48 hours after the intervention but on day 3 experienced a sentinel bleed, went into cardiopulmonary arrest and died. Conclusion: One should suspect hemorrhage into a known pancreatic pseudocyst if there is a sudden increase in pseudocyst size, an overlying bruit is detected or there is evidence of GI bleeding without obvious source seen on EGD. Common approaches to treatment of hemorrhagic pseudocyst include surgical resection of the cyst and pseudoaneurysm, surgical ligation of the artery proximal and distal to the pseudoaneurysm and internal or external pseudocyst drainage, or angiographic embolotherapy. Due to the high mortality associated with pancreatic pseudocyst-related arterial hemorrhage and pseudoaneurym rupture, early identification of the source of hemorrhage and rapid intervention are necessary.Figure: Pseudoaneurysm (white arrow).

Pancreaticopleural Fistula with Hemothorax

Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis. We report a case of pancreaticopleural fistula that was presented with right-sided hemothorax. A 49-year-old male with a history of chronic alcoholism was presented with a month of dyspnea. A chest radiography showed a right-sided massive pleural effusion with old-blood-colored fluids and amylase levels of 1,020 IU/L. On the chest computerized tomography (CT), there was pleural effusion and a well-defined tract from the posterior mediastinum to the pseudocyst in the tail of the pancreas. Even with conservative treatment with closed thoracostomy, octreotide and gabexate mesilate, he developed hemothorax. Abdominal CT revealed an increase of the hemorrhagic pancreatic pseudocyst. Distal pancreatectomy with splenectomy and external drainage of the pancreaticopleural fistula on the posterior mediasternum were performed. The patient had an uneventful course and was discharged on the 27th postoperative day. Management of pancreaticopleural fistula is multimodal included medication, endoscopic stenting and surgery. Surgery in pancreaticopleural fistula might be beneficial in selective cases. (J Korean Surg Soc 2009;76:187-191)

Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage

Background Pancreatic pseudocyst bleeding is an unusual entity of acute abdomen, usually occurring among alcoholics. A high mortality developed in patients with conservative treatment of hemorrhagic pancreatic pseudocyst. We report a 37-year-old male with a pseudoaneurysm in the tail of the pancreas presenting with sudden onset of abdominal pain and swelling. Emergency laparotomy after blood transfusion and fluid resusitation was successfully performed. Methods An abdominal radiography showed multiple calcifications in the epigastric area. Computed tomography of the abdomen showed a cystic lesion with a calcified wall in the tail of the pancreas and a large amount of ascites. After contrast enhancement, there was hemorrhage into the pancreatic pseudocyst with extravasation of contrast into the peritoneal cavity. Results At operation, active bleeding was noted from a ruptured pseudocyst in the tail of the pancreas and ligation of the bleeding vessel was done. Conclusions Hemorrhage into the pancreatic pseudocyst associated with intraperitoneal bleeding is a potentially life threatening condition. Emergency surgical treatment should be carried out as soon as possible.

An unusual presentation of a hemorrhagic pancreatic pseudocyst

An unusual presentation of a hemorrhagic pancreatic pseudocyst

An unusual presentation of a hemorrhagic pancreatic pseudocyst

An 80-year-old man presented for the evaluation of weight loss, early satiety, and constipation that had persisted for 8 months. The past history included resection of a benign right renal mass 30 years earlier and prostatic cancer treated with external-beam radiation. He denied a prior history of biliary or pancreatic disease, trauma, or alcohol or illicit drug intake. Physical examination revealed a nontender, 20-cm epigastric mass that extended from the left upper quadrant to the level of the umbilicus. A computed tomography (CT) scan demonstrated a 15-×13-cm septated cystic mass that originated from within the body and tail of the pancreas; several left renal cysts were also seen (Fig 1). An ultrasonography demonstrated a complex, multicystic mass adjacent to the pancreatic body and tail without evidence of cholelithiasis (Fig 2). The following serum assays were normal: complete blood count, calcium, albumin, amylase, lipase, triglycerides, and liver enzymes. The blood urea nitrogen and creatinine, however, were elevated to 17 mg/dL and 1.7 mg/dL, respectively. Additionally, serum prostate-specific antigen, carcinoembryonic antigen, and CA19-9 levels were normal.

A case report of upper gastrointestinal bleeding from hemorrhagic pancreatic pseudocyst by penetration to the stomach

A case report of upper gastrointestinal bleeding from hemorrhagic pancreatic pseudocyst by penetration to the stomach