Introduction and importance: Hemorrhage into a pancreatic pseudocyst is rare but potentially fatal. Interventional radiology-guided transcatheter arterial embolization (TAE) is often first-line therapy; however, rebleeding is common, and surgery may be required. Inflammation from pancreatitis can make surgery technically challenging, underscoring the importance of careful management. Case presentation: A 68‑year‑old Japanese man with chronic pancreatitis and heavy alcohol use presented with acute abdominal pain. Computed tomography revealed a 25 mm hemorrhagic cystic lesion in the pancreatic head containing a pseudoaneurysm, superior mesenteric vein (SMV) thrombosis, and inflammatory fat stranding. Initial TAE controlled bleeding from a branch of the dorsal pancreatic artery, but recurrent hemorrhage occurred 7 months later, requiring repeat TAE. Three months later, another episode from the anterior superior pancreaticoduodenal artery was embolized. Because of repeated bleeding and persistent SMV thrombosis, pancreaticoduodenectomy with SMV resection and reconstruction was performed using an external iliac vein graft under an Anthron‑coated catheter shunt. The postoperative course was uneventful, and the patient has remained symptom‑free for 2 years. Clinical discussion: This case illustrates the complexity of managing hemorrhagic pancreatic pseudocyst with SMV thrombosis and recurrent bleeding. While endovascular therapy can provide temporary control, repeated episodes may necessitate definitive surgery. An intraoperative Anthron-coated catheter shunt enabled safe SMV reconstruction in this case despite extensive thrombosis. Conclusion: Surgical intervention should be considered in select patients with recurrent hemorrhage and complicating vascular pathology. This case adds to the limited literature and may inform future treatment strategies.

Endoscopic rescue after lumen-apposing metal stent deployment failure during endoscopic ultrasound-guided drainage of a giant pancreatic pseudocyst

Children with rare tumours and malformations may benefit from innovative imaging, including patient-specific 3D models that can enhance communication and surgical planning. The primary aim was to evaluate the impact of patient-specific 3D models on communication with families. The secondary aims were to assess their influence on medical management and to establish an efficient post-processing workflow. From 2021 to 2024, we prospectively included patients aged 3 months to 18 years with rare tumours or malformations. Families completed questionnaires before and after the presentation of a 3D model generated from MRI sequences, including peripheral nerve tractography. Treating physicians completed a separate questionnaire before surgical planning. Analyses were performed in R. Among 21 patients, diagnoses included 11 tumours, 8 malformations, 1 trauma, and 1 pancreatic pseudo-cyst. Likert scale responses showed improved family understanding after viewing the 3D model (mean score 3.94 to 4.67) and a high overall evaluation (mean 4.61). Physicians also rated the models positively. An efficient image post-processing workflow was defined. Although manual 3D reconstruction remains time-consuming, these preliminary results show that colourful, patient-specific 3D models substantially improve family communication and support clinical decision-making. They also highlight the need for supporting the development of MRI-based automated segmentation softwares using deep neural networks, which are clinically approved and usable in routine practice.

Acute pancreatitis is an uncommon but clinically important complication in people living with HIV (PLWH) and has been linked to HIV itself, older nucleoside reverse transcriptase inhibitors, protease inhibitors via hypertriglyceridemia, and multiple opportunistic or metabolic comorbidities. Atraumatic splenic rupture (ASR) is rare and has been described in association with acute or chronic pancreatitis and, more rarely, with HIV infection. However, the coexistence of chronic HIV infection, pancreatitis with pancreatic tail pseudocyst, and ASR has seldom been reported. We present a complex case highlighting the interaction between long-standing HIV infection, chronic pancreatitis, and splenic injury. To our knowledge, no previous report has described chronic HIV infection complicated simultaneously by acute-on-chronic pancreatitis, a pancreatic tail pseudocyst, and atraumatic splenic rupture. A 35-year-old man with a 9-year history of HIV infection on antiretroviral therapy (ART) presented with acute worsening of upper abdominal pain and dizziness on the background of intermittent epigastric pain over one year. He had no history of abdominal trauma, alcohol abuse, gallstones, or hypertriglyceridemia, and had never received didanosine or stavudine. Initial assessment revealed pallor, hypotension, generalized abdominal tenderness with peritoneal signs, severe anemia, leukocytosis, and markedly elevated serum amylase and lipase levels. Contrast-enhanced abdominal CT showed hemoperitoneum, irregular laceration and heterogeneous enhancement of the spleen, chronic pancreatitis with atrophic, calcified pancreas and dilated main pancreatic duct, and a pseudocyst in the pancreatic tail abutting the splenic hilum. Emergency laparotomy revealed approximately 1500 mL of hemoperitoneum, a ruptured upper pole splenic laceration extending towards the hilum, and a pancreatic tail pseudocyst adherent to the splenic hilum. Splenectomy plus distal pancreatectomy with drainage were performed. Pathology confirmed chronic pancreatitis with pseudocyst formation and splenic rupture without malignancy. Postoperative recovery was uneventful apart from reactive thrombocytosis, which was managed with antiplatelet therapy. The patient remained well with no recurrence of pancreatitis or splenic complications at 15-month follow-up. This case illustrates a plausible "pancreas-spleen axis" in which chronic pancreatitis with a pancreatic tail pseudocyst leads to local vascular and parenchymal fragility, predisposing to ASR in a patient with chronic HIV infection and incomplete immune reconstitution. It emphasizes the need to consider ASR in PLWH presenting with acute abdomen, particularly when imaging shows pancreatic tail pathology. Early CT, prompt surgical decision-making, and multidisciplinary management between infectious disease specialists and surgeons are critical for favorable outcomes.

ABSTRACTPancreatic pseudocysts are encapsulated, enzyme‐rich peripancreatic fluid collections that typically develop following acute or chronic pancreatitis due to pancreatic ductal disruption. While commonly localized to the lesser sac, rare mediastinal extension may occur, presenting with nonspecific thoracic symptoms such as chest pain, dyspnea, or dysphagia. Cross‐sectional imaging (CT/MRI) is essential for diagnosis. Management is individualized, ranging from conservative medical therapy to endoscopic, percutaneous, or surgical drainage based on symptom severity, complications, and anatomical considerations. We report the case of a 26‐year‐old male with a history of alcohol use and smoking, presenting with cough and dyspnea. Clinical examination revealed tachypnea, hypoxia, and signs of right‐sided pleural effusion. Chest X‐ray revealed complete opacification of the right hemithorax. Diagnostic thoracentesis yielded amylase‐rich pleural fluid (11,545 IU/L). Serum amylase and lipase were also elevated. Contrast‐enhanced CT imaging demonstrated acute necrotizing pancreatitis with peripancreatic collections extending into the thoracic cavity via the esophageal hiatus, confirming a pancreatic pseudocyst with secondary massive right‐sided amylase‐rich pleural effusion. The patient was managed conservatively with antibiotics, octreotide, and ultrasound‐guided pigtail catheter drainage. The clinical course was favorable, with complete symptomatic resolution and no evidence of recurrence on follow‐up. This case underscores a rare but significant thoracic complication of acute pancreatitis manifesting as massive pleural effusion, mimicking thoracic pathology. Thus, accurate diagnosis using contrast‐enhanced CT and MRCP, along with tailored management from conservative therapy to invasive drainage, is crucial. Early recognition and multidisciplinary care ensure favorable outcomes, as highlighted in this case.

Fibrocalculous pancreatic diabetes (FCPD) is an unique nonalcoholic form of chronic pancreatitis seen in tropical countries, characterized by pancreatic calcification in addition to pancreatic chronic inflammation and diabetes. In patients with FCPD, chronic and recurrent bouts of pancreatitis lead to calcifications followed by the development of diabetes. Pancreatic pseudocysts occur in 20%-40% of cases of chronic pancreatitis, and two-thirds of the pseudocysts occur in patients with alcohol related chronic pancreatitis. The association of FCPD with pancreatic pseudocysts is extremely rare. Till date only a single case of case of tropical chronic pancreatitis with giant pseudocyst and glucose intolerance was reported in a 16-year-old woman with cassava consumption. We report a novel case of multiple pseudocysts of the pancreas in a case of FCPD.

Interventional endoscopic ultrasound (EUS) has become established as an important diagnostic and therapeutic pillar in diseases of the hepatobiliary and pancreatic system. It complements or replaces conventional strategies and expands the spectrum of endoscopic procedures but requires ahigh level of expertise and interdisciplinary interpretation of indications. One focus is the treatment of necrotizing pancreatitis: The use of EUS-guided drainage is part of the step-up approach and is superior to surgical procedures. Lumen-apposing metal stents (LAMS) facilitate the access and enable direct necrosectomy but double pigtail stents also retain their role. Pancreatic pseudocysts and postoperative fluid accumulation can also be effectively drained endoscopically. In complex bile duct stenoses, EUS-guided drainage is aback-up method, for example as arendezvous technique, hepaticogastrostomy or choledochoduodenostomy, especially when an endoscopic retrograde cholangiopancreatography (ERCP) is not technically possible. Similarly, the pancreatic duct can be reached endosonographically, although EUS-guided drainage is only advisable under strict clinical indications. Gallbladder drainage using LAMS is an alternative to percutaneous drainage in severe cholecystitis without surgical options. The EUS gastroenterostomy is increasingly replacing surgical procedures for the treatment of gastric outlet obstructions and also enables the endoscopic ultrasound-directed transgastric ERCP (EDGE) procedure for easier ERCP in an anatomically altered stomach. Other emerging fields include EUS-guided ablation of small insulinomas, endovascular interventions for portal hypertension and celiac plexus block, although the benefits of the latter are limited.

Comparison of Efficacy and Outcome of Different Management Strategies for Pancreatic Pseudocysts in Children: A Systematic Review and Meta-Analysis.

To assess the accuracy and safety of CT-guided percutaneous core-needle biopsies of pancreatic lesions suspected to be malignant based on MRI or CT scans. This retrospective study analyzed CT-guided percutaneous biopsies of suspicious pancreatic lesions performed at our university hospital. Biopsy was performed using a 17G coaxial needle and an 18G core biopsy needle. Data on patient characteristics, lesions, procedures, and histologic results were recorded. A total of 90 patients (58.9% males, mean age 65 ± 12.2years) underwent CT-guided percutaneous biopsies. The lesions had a mean size of 36.8 ± 12.2mm and were predominantly located in the pancreatic head 61.1% (55/90). Technical success was achieved in all biopsies 100% (90/90). Most procedures 96.7% (87/90) were performed using direct access routes, while 3.3% (3/90) required indirect transhepatic or transgastric approaches. Among the biopsies, 65.6% (59/90) confirmed malignancy, with adenocarcinoma as the most common malignant subtype representing 55.6% (50/90) of all cases. The rate of non-malignant findings was 26.7% (24/90) including chronic pancreatitis at a rate of 5.6% (5/90) as well as pancreatic pseudocysts and pancreatic cystadenoma each at a rate of 2.2% (2/90), among others. A total of seven cases were identified as false negatives confirmed, but malignancy was later confirmed after re-biopsy or surgery. The initial diagnostic accuracy was 92.2% (83/90). The rate of major complications was 1.1% (1/90), and a total of two minor complicationsat a rate of 2.2%were observed. This study shows that CT-guided pancreatic biopsy is a safe procedure with high diagnostic accuracy.

Endoscopic ultrasound-guided treatment of splenic artery pseudoaneurysm and pancreatic pseudocyst

Successful pancreatic pseudocyst drainage via the endoscopic minor papilla approach using a novel drill dilator

Endoscopic Ultrasound-Guided Drainage of a Subcapsular Hepatic Pancreatic Pseudocyst: A Novel Application of a Lumen-Apposing Metal Stent with Visualization of Fluid Communication Pathways

Background: Acute pancreatitis (AP) is an inflammatory disease primarily caused by gallstones and alcohol consumption. Its clinical presentation varies significantly, ranging from mild interstitial edematous pancreatitis to severe necrotizing forms. The Revised Atlanta Classification establishes the standard for defining the severity of the disease and categorizing its local complications into four distinct types: acute peripancreatic fluid collections (APFC), acute necrotic collections (ANC), pancreatic pseudocysts, and walled-off necrosis (WON). Aim: The aim of this study was to review the current literature regarding the epidemiology, pathophysiology, diagnostic criteria, and management strategies for the local complications of acute pancreatitis. Materials and Methods: The review included scientific papers sourced from the PubMed and Google Scholar databases. Results: The diagnosis and characterization of local complications rely heavily on imaging modalities. While Contrast-Enhanced Computed Tomography remains the standard tool, Magnetic Resonance Imaging and Endoscopic Ultrasound demonstrate superior accuracy in detecting solid necrotic debris. Distinguishing between fluid-only collections (APFC, pseudocyst) and those containing necrosis (ANC, WON) is critical, as it dictates the therapeutic approach. The review highlights that while APFCs often resolve spontaneously, necrotic collections carry a higher risk of infection and mortality. Management strategies have evolved significantly, moving away from open surgery toward minimally invasive methods. Conclusions: Accurate classification of local complications based on the Revised Atlanta Classification is essential for guiding clinical decision-making. Contemporary management of AP complications favors a "step-up" approach, prioritizing conservative treatment and minimally invasive endoscopic interventions over traditional surgical necrosectomy to reduce morbidity and improve patient outcomes.

Pancreatic pseudocysts in children are uncommon, and while most resolve spontaneously, a subset requires intervention. Endoscopic ultrasound-guided drainage has become the preferred modality in adults; however, its use in pediatrics is limited by patient size, anatomy, and availability of appropriately sized equipment. This manuscript reviews operative management strategies for pediatric pancreatic pseudocysts when endoscopic drainage is not feasible. Surgical alternatives include laparoscopic cystogastrostomy, which offers minimally invasive access for cyst drainage; open cystogastrostomy, which remains a reliable option when exposure, anatomy, or safety concerns preclude laparoscopy; and stapler-assisted techniques that facilitate creation of a wide, secure cystogastrostomy to reduce recurrence. Within this framework, we present an illustrative case of an eight-year-old patient with a large retrogastric pseudocyst who was not a candidate for endoscopic drainage and underwent successful open, stapler-assisted transgastric cystogastrostomy. The outcome highlights the continued relevance of surgical drainage as a safe and effective treatment pathway when endoscopic intervention cannot be performed.

Research on the classification of pancreatic pseudocysts based on individualized treatment protocols

Massive Upper Gastrointestinal Bleeding Due to Rupture of a Pancreatic Pseudocyst into the Duodenum.

Traumatic pancreatic injury successfully bridged through a giant pancreatic pseudocyst

Introduction: The management of symptomatic peripancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off necrosis (WON), remains a clinical challenge. Methods: We conducted a single-center retrospective cohort study to compare the efficacy, safety, and cost of endoscopic drainage (lumen-apposing metal stent vs. double pigtail stent) and percutaneous drainage for PFCs. From an initial cohort of 75 patients with symptomatic PFCs between 2020 and 2025, 63 underwent drainage procedures. Primary endpoints were the clinical success, defined as >50% collection size reduction, and the need for direct endoscopic necrosectomy (DEN). Secondary endpoints included adverse events, recurrence rates, length of hospital stay (LOS), and procedural costs. Results: In our study, endoscopic drainage proved high clinical efficacy for PFCs, especially PPs. Once a technique was chosen, complication rates were comparable, indicating no clear safety advantage for either approach. While percutaneous drainage relieved symptoms and reduced collection size in half of the cases, the other half had only transient or partial improvement. When comparing endoscopic drainage techniques, median costs and length of hospital stay trended higher for lumen-apposing metal stent (LAMS) than double pigtail stent (DPS), but the differences were not statistically significant. However, the “other” group proved markedly higher costs and the longest mean hospital stay. Conclusions: The choice of drainage technique impacts short-term outcomes and safety profile in managing PFCs. Our findings support a tailored, step-up approach, prioritizing endoscopic ultrasound-guided drainage based on PFC characteristics to optimize clinical outcomes.

Direct comparison of efficacy and safety of metallic stents versus plastic stents for endoscopic drainage of pancreatic pseudocysts: a systematic review and meta-analysis.

Clinical outcome and risk factors for recurrence of percutaneous external drainage in treating pediatric pancreatic pseudocysts.