North Alabama Medical Center Florence, AL, United States
Brigette Thomas, MD, Maged Ghaly, MD, Anila Singh, MD, Khushdeep Chahal, MD North Alabama Medical Center, Florence, AL
Introduction: Pseudocyst are an abnormal fluid collection with well-defined walls, generally in the peripancreatic or intrapancreatic areas. It’s rare to see hepatic or splenic pseudocyst and even more rare to have multiple abdominal pseudocyst. Only about 50 cases reported to date. Here we have a patient presenting with an acute exacerbation of chronic pancreatitis with pseudocyst and multiple complex fluid collections in the gastrum, spleen and liver with rapid expansion within one month. Extrapancreatic fluid collections can be overlooked leading to complications varying from prolonged fever to life threatening events such as abscess or erosion of blood vessels with hematoma.
Case Description/Methods: A 37-year-old female with chronic pancreatitis presents with pancreatitis exacerbation and shock. She was recently hospitalized for complicated pseudocyst. Previous CT showed perisplenic, greater curvature and splenic pseudocyst with ascites. She was discharged with follow-up instructions. Blood cultures were drawn and were negative. Patient had leukocytosis of 28.3 and hemoglobin of 9. Leukocytosis increased to 36 and hemoglobin dropped to 7.3. Repeat CT revealed expansion of previous fluid collections with splenic hematoma and loculated fluid collection along anterior abdominal wall. Physical exam revealed soft abdomen with sluggish bowel sounds, tenderness all throughout. Blood cultures were negative. Patient was started on treatment for acute pancreatitis and transferred to a tertiary care facility for total pancreatectomy or percutaneous drain placement. Determination was made at admitting facility to place multiple percutaneous drains. Pancreatic pseudocyst is caused by exudation of proteolytic enzymes into peripancreatic tissue. These enzymes facilitate the escape of fluid along established tissue plains like the course of splenic vessels into the parenchyma of the spleen into the foramen of Winslow causing pancreatic ascites and peritonitis that can be life threatening. Erosion of the splenic vessels can lead to hematoma.
Discussion: In this case MRI is superior to CT imaging to better characterize fluid collections which help direct management and determine the need for escalation of care. To conclude, pancreatic pseudocyst are seen in severe pancreatitis and could lead to fatalities. Our case highlights the importance of proper imaging needed to evaluate early surgical intervention with close monitoring in high acuity care settings.
Figure: Progression of multiple pseudocyst
Disclosures: Brigette Thomas indicated no relevant financial relationships. Maged Ghaly indicated no relevant financial relationships. Anila Singh indicated no relevant financial relationships. Khushdeep Chahal indicated no relevant financial relationships.
Brigette Thomas, MD, Maged Ghaly, MD, Anila Singh, MD, Khushdeep Chahal, MD. P2175 - Disseminated Intra Abdominal Pancreatic Pseudocysts as a Complication of Severe Pancreatitis: A Rare Case of Hepatic, Splenic, Gastric Wall and Anterior Abdominal Wall Pancreatic Pseudocysts, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.