Sharique Nazir, MD, Veshal Malhotra, MA, Jacques Duperval, MD, Fausto Vinces, DO, FACOS
Brooklyn Hospital Center NY, Lutheran Medical Center NY
Pancreatic Pseudocysts occur when extreme pressure within the pancreatic duct causes disruption and allows extravasation of pancreatic juices into cavities surrounded by a fibrous wall made of collagen and granulation tissue. Lacking epithelium in their walls, these pseudocysts can enlarge and fully mature in 4-6 weeks thus causing bowel obstruction, jaundice, cholangitis, thrombosis and ischemia. Further, sepsis can precipitate if ruptured or infected; therefore pancreatic pseudocysts should not be overlooked in the differential diagnosis of pancreatitis or choledocholithiasis as initial mismanagement of the patient may occur. Additional understanding of pancreatic pseudocysts can help diagnose and treat this often-disregarded condition.
A 40 year-old female with past medical history of hypertension and asthma presented with symptomatic cholithiasis for five months. Abdominal sonogram confirmed calculus of the gallbladder and the patient was sent for immediate laparoscopic cholecystectomy. During insertion of the Hasson Cannula, a sudden release of pressure was observed and the procedure was converted to a laparotomy and an enterotomy was ruled out. Following the cholecystectomy, the patient had prolonged ileus with episodes of vomiting, abdominal distention and diarrhea thus Flagyl was empirically given and a nasogastric tube was placed. After eleven days in the hospital, her bowel function normalized she was discharged.
Three weeks later, the patient returned with complaints of abdominal pain, distension, nausea, and vomiting. A CT scan demonstrated multiple large loculated fluid collections throughout the pancreas, peripancreatic and mesenteric regions consistent with pancreatic pseudocysts. Her largest collection measured 13x8x9 cm with her amylase and lipase elevated to 373 IU/L and 246 IU/L respectively. Only small portions of the pancreas enhanced normally and the multifocal nature suggested a pancreatic duct laceration or fistula. She was placed NPO with TPN, and began Octreotide therapy to prevent pancreatic secretion. Three days later she went for CT guided drainage with an 8F pigtail catheter for emergent decompression. A repeat CT scan five days later showed resolving fluid collection but only a modest decrease in size of the pseudocyst at the pancreatic body and head while MRCP revealed a non-dilated biliary tree. Follow up CT a week later showed an interval increase in right-upper-quadrant fluid collection and it was decided further intervention was appropriate. Using Endoscopic Ultrasound guided drainage, the cysts have since resolved and the patient has been discharged.
The incidence of pancreatic pseudocysts is 5-16% in pancreatitis patients with heavy alcohol consumption and gallstones accounting for a majority of these cases. This case illustrates the importance of recognizing pancreatic pseudocysts as a differential diagnosis for a patient presenting with cholelithiasis. While trans-abdominal ultrasounds are generally regarded as the initial study of choice, often pancreatic pseudocysts can go undiagnosed using this modality. CT scans, which have the highest diagnostic value, are a compulsory study in suspected pseudocysts and can help greatly with patient management. Often they can reduce the need for expensive and unnecessary surgical procedures. With success rates of >80%, endoscopic drainage is the treatment of choice for large or multiple pseudocysts however other options are available.
Session: Poster Presentation
Program Number: P323