Spontaneous Rupture Of Pancreatic Pseudocyst Research Articles

Spontaneous Hemorrhagic Rupture of Pancreatic Pseudocyst

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].

Pancreatic Panniculitis: A Harbinger of Systemic Inflammatory Response Syndrome From Spontaneous Rupture of Massive Pancreatic Pseudocyst

Introduction: Pancreatic panniculitis (PP) is an uncommon manifestation of pancreatic diseases. PP in association with spontaneous rupture of a pancreatic pseudocyst has been rarely reported in the literature. Case: A 34-year-old female with history of acute alcoholic pancreatitis presented to the ED with abdominal pain, nausea and vomiting. She reported alcohol use a few days prior to the onset of symptoms. Lipase was 2,040 IU/L (normal 11-82 IU/L). CT of the abdomen/pelvis showed peripancreatic fat stranding and fluid, consistent with acute pancreatitis, and a few cystic structures adjacent to the pancreas believed to be developing pseudocysts. Her symptoms improved slowly with conservative management and she was discharged on day 6. A week later, she returned to ED with recurrent pain, nausea, vomiting, and new erythematous tender nodules on lower extremities (Figure 1A). CT abdomen/pelvis now revealed a new massive pseudocyst within the left side of the abdomen, anterior to the body and tail of the pancreas, measuring 20 x 12 x 15 cm (Figure 2). During CT-guided drainage of the pseudocyst, it was discovered that the pseudocyst had already spontaneously ruptured into the peritoneum. Trans-gastric drainage of the residual pseudocyst was unsuccessful; 1659 cc of ascites was drained. Following the procedure, she developed worsening pain, tachycardia and leukocytosis. She had emergent diagnostic laparoscopy, irrigation and lavage of abdomen, and placement of abdominal drains. She was discharged 8 days post-operatively. Three days later, she was re-hospitalized for recurrent gastrointestinal symptoms. The painful skin nodules had progressed to the upper extremities (Figure 1B). CT abdomen/pelvis now revealed hemorrhagic transformation of the remaining cyst and necrotic changes in the pancreatic head. After stabilization, she underwent skin biopsy which showed dense inflammation with many neutrophils and necrosis, consistent with PP (Figure 3). Her symptoms improved slowly over 2 weeks with conservative management and she was discharged home with subsequent resolution of her skin lesions a week later.1388_A.tif Figure 1: Erythematous tender skin nodules on the legs (A) and arms (B) bilaterally in a patient with massive pancreatic pseudocyst after recurrent acute alcoholic pancreatitis.1388_B.tif Figure 2: Computerized tomography of the abdomen and pelvis with intravenous contrast showing a massive pseudocyst within the left side of the abdomen.1388_C.tif Figure 3: Skin biopsy showing dense inflammation with many neutrophils necrosis, some eosinophils and macrophage/giant cells, consistent with pancreatic panniculitis, in a patient with spontaneous rupture of pancreatic pseudocyst.Discussion: PP is an uncommon necrosis of subcutaneous fat that, may be a harbinger of an underlying pancreatic disorder (including pancreatitis, cancer and pseudocyst). Prompt recognition and appropriate management, by addressing the underlying pancreatic disease, may allow for earlier treatment that could improve clinical outcomes.

Recurrent Pleural Effusion Complicating Spontaneous Rupture of Pancreatic Pseudocyst

Introduction: Pancreatic pseudocysts are commonly seen complicating acute pancreatitis with a reported prevalence of 6-18.5 % and higher rates in cases of chronic pancreatitis 20 to 40%. We present interesting case of spontaneous rupture of pseudocyst into the pleural cavity presented with recurrent pleural effusion. Case Description: A 74-year-old male patient with medical history of necrotizing pancreatitis complicated with pancreatic pseudocyst admitted with abdominal pain and dyspnea. Patient was diagnosed with acute pancreatitis 1 month ago of unknown cause then re-admitted 4 weeks later with necrotizing pancreatitis managed conservatively. CXR then showed left side pleural effusion. Thoracentesis was done with removal of 450 cc exudative fluid with total protein of more than 3 g/dl and negative cytology and culture results. Initial vitals were BP 84/52, HR 106 bpm, temperature 97.8 F, respirations 18 bpm and oxygen saturation 97% on 2-liter oxygen. He had abdominal distention with right upper quadrant tenderness and bilateral lower extremity edema. Labs showed ammonia level of 38 ug/dl, BUN 33 mg/dl, Cr. 1.67micromol/L, albumin 2.4 g/L, lipase 172 U/L, Alk phos 187 IU/L, wbc 19.3, and hgb 10.5 g/dl. CXR showed left sided pleural effusion. CT abdomen revealed worsening of the peripancreatic fluid collection with extension into the left upper quadrant, retroperitoneum, compression of the stomach and upper abdominal venous structures. Patient had free fluid in the colonic gutters, around the liver and spleen and in the pelvis and loculated pleural fluid at the left lung base. Fluid and antibiotics were started and CT guided percutaneous drainage of pancreatic pseduocyst was done. Thoracentesis was repeated with the removal of 450cc transduative fluid with elevated amylase level 223, normal cholesterol 34, triglyceride 18, total protein < 3 and albumin 1.5. Patient had normal IgG4 and CA 19-9 level. Patient expired few days later. Discussion: Pleural effusion complicating acute pancreatitis is usually small and left sided, recurrent, and refractory to drainage. It normally has amylase level of 1000 U/L and protein concentration above 3 g/dl. Pancreaticopleural fistula (PPF) have been reported in 2.3 to 4.5 % patients with pancreatic pseudocyst. Diagnosis need CT scan, ultrasound or ERCP. Management includes drainage of effusion with chest tube and if that fails, then percutaneous or endoscopic drainage of the pseudocyst should be considered.2914 Figure 1. abdomen showed fluid collection around the pancreas, retro peritoneum, barely visible normal pancreatic tissue and left sided pleural effusion [Arrows]

Spontaneous Rupture of Pancreatic Pseudocyst: Report of Two Cases.

Introduction. Pancreatic pseudocysts are a common complication of acute pancreatitis. Pancreatic pseudocyst's natural history ranges between its spontaneous regression and the settlement of serious complications if untreated, such as splenic complications, hemorrhage, infection, biliary complications, portal hypertension, and rupture. The rupture of a pancreatic pseudocyst to the peritoneal cavity is a dangerous complication leading to severe peritonitis and septic conditions. It requires emergent surgical exploration that is often of great technical difficulty and with important morbidity and mortality. Case Study. We present two cases of spontaneous rupture of pancreatic pseudocysts, managed differently according to the local and systemic conditions. Conclusion. The best surgical choice is the internal drainage of the cyst to the GI tract; however, in some conditions, the external drainage is the only choice available.

Uncomplicated spontaneous rupture of pancreatic pseudocyst into stomach: A case report

Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography (CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.

Spontaneous Rupture of Pancreatic Pseudocyst into Duodenal Ulcer

Spontaneous Rupture of Pancreatic Pseudocyst into Duodenal Ulcer