Spontaneous Resolution of Pancreatic Gastric Fistula

Pancreatic pseudocyst is one of the common complications of acute and chronic pancreatitis and has variable natural history. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection. This case presented a 46-year-old man with a pancreatic pseudocyst resulting from a complication of acute pancreatitis. This resolved spontaneously through the formation of a fistula between the pseudocyst and stomach. The fistula tract was also occluded spontaneously and the patient recovered without any complication or need for surgical treatment. The patient has been good progress at a two year follow up after spontaneous resolution of the fistula.     

Rupture of a bleeding pancreatic pseudocyst into the stomach

A bleeding pancreatic pseudocyst following pancreatitis is a severe complication that can lead to massive gastrointestinal bleeding. Rupture of such a pseudocyst into the stomach is rare. We report herein a case of rupture of a bleeding pseudocyst into the stomach in a patient who was successfully treated with emergency surgery. A 60‐year‐old Japanese man with a history of chronic alcoholic pancreatitis with a pancreatic tail pseudocyst was referred to us because of hematemesis. The cavity of the pseudocyst, which was 3–cm in size and whose wall adhered to the stomach, was enhanced by dynamic bolus computed tomography (CT) in the late arterial phase. Splenic angiography revealed a bleeding pseudocyst in the splenic hilum. Embolization of the pseudocyst failed, because of arterial spasm. A distal pancreatectomy, splenectomy, and total gastrectomy were performed. The wall of the pseudocyst consisted of the pancreatic tail, granulation tissue, and the posterior wall of the stomach. The patient's postoperative course was uneventful. In the management of massive bleeding from a pseudocyst, early diagnosis with dynamic bolus CT and angiography is essential. A bleeding pseudocyst should be considered to be a lethal complication, but it can possibly be treated with a combination of angiographic embolization and surgery.     

Uncomplicated Spontaneous Rupture of the Pancreatic Pseudocyst into the Gut – CT Documentation: A Series of Two Cases

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 herein two cases of uncomplicated spontaneous rupture of a pancreatic pseudocyst into the stomach with complete resolution.     

Two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization

Hemosuccus pancreaticus is a rare complication of chronic pancreatitis. We report two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization (TAE). The first patient was a 47-year-old man with alcoholic chronic pancreatitis. He presented with upper abdominal pain and hematemesis. Upper GI endoscopy failed to detect the source of bleeding, but computed tomography (CT) showed a hypervascular area about 3?cm in diameter in a pseudocyst at the pancreatic tail. Angiography revealed a pseudoaneurysm in the caudal pancreatic artery. Hematemesis was considered to be due to rupture of the pseudoaneurysm. TAE of the splenic artery was performed selectively, and this successfully stopped the bleeding. The second patient was a 52-year-old man with alcoholic chronic pancreatitis. He presented with hematemesis. Upper GI endoscopy detected bleeding from the papilla of Vater. CT showed hemorrhage in a pseudocyst at the pancreatic body. Angiography revealed angiogenesis around the pseudocyst. Hematemesis was considered to result from rupture of the pseudoaneurysm. TAE of the dorsal pancreatic artery and posterior superior pancreaticoduodenal artery was performed and hemostasis was achieved. We conclude that TAE is a minimally invasive and highly effective treatment for hemosuccus pancreaticus.     

Pancreatic pseudocystocolonic fistula treated without surgical or endoscopic intervention

We report here a case of pancreatic pseudocystocolic fistula that was treated without surgical or endoscopic intervention.A 76-year-old woman,presenting with a fever and epigastric pain,was referred to our institution.Three months prior to this admission,the patient had been admitted to the hospital for acute pancreatitis.Abdominal computerized tomography(CT)revealed a 9 cm pseudocyst containing air,and a fistular opening was observed via colonoscopy.After colonoscopy,the abdominal pain was slightly improved,the fever subsided and laboratory results showed decreased C-reactive protein levels.The observed improvement was likely due to the cleansing of the bowel,which induced spontaneous drainage from the pseudocyst into the colon.Antibiotic therapy was administered and daily bowel cleansing was performed using a polyethylene glycol solution.After three weeks,a follow-up CT revealed that the size of the pseudocyst had decreased significantly from 9 to 5.3 cm.In addition,laboratory tests were improved.The patient was able to resume a normal diet and was discharged in good overall health from the hospital,without aggravation of the symptoms.A colonoscopy performed 3 mo later and a follow-up CT performed 6 mo later confirmed that both the fistula and pseudocyst had completely disappeared.     

A case of chronic pancreatitis complicated by massive pericardial and right pleural effusion

A 42-year-old man was admitted complaining of dyspnea. Chest X-ray showed an increase in cardiac size, and echocardiography revealed a large volume of pericardial effusion. Pancreatic enzyme levels were elevated in both serum and pericardial effusion. Computed tomography and endoscopic retrograde pancreatography demonstrated a fistula connecting a pancreatic pseudocyst with the pericardium and the right pleural cavity. Massive pericardial and right pleural effusion is an extremely rare complication of chronic pancreatitis. In this case, computed tomography and endoscopic retrograde pancreatography were useful for diagnosing the fistula.     

A Case of Postsurgical Pancreatic Pseudocyst Treated by Endoscopic Cystogastrostomy

Pancreatic pseudocyst after pancreatic surgery is a relatively rare condition and conservative therapy is the common treatment of choice. When symptoms persist or complications follow, however, surgical treatment is considered. There have been reports on endoscopic cystoenterostomy since the early 1980s. We herein describe a case of postsurgical pancreatic pseudocyst treated successfully by endoscopic cystogastrostomy. A nineteen-year-old female showing left hypochondralgia and back pain with elevation of her serum amylase level, who had undergone enucleation of a solid cystic tumor in the body of the pancreas, was referred to our department. She was diagnosed as having a pseudocyst of the pancreas 5.8×4.5 cm in size at the site of enucleation by US and CT. Endoscopic retrograde pancreatography and endoscopic ultrasonography performed simultaneously revealed obstruction of the main pancreatic duct and a cystic change in the body-tail of the pancreas just behind the gastric wall of the upper body. An extrinsic compression was seen in the posterior wall of the upper body of the stomach endoscopically. An incision was made using a sphincterotome. A pigtail stent, 7.2 Fr in size, was placed to keep the patency of the fistula, which was removed one and a half months later. Her symptoms showed great improvement immediately after the procedure. Follow-up CT demonstrated no recurrence of the pseudocyst.     

Complete recovery after spontaneous drainage of pancreatic abscess into the stomach.

Pancreatic abscess is a dreaded complication of acute pancreatitis, with a high death rate even with aggressive surgical treatment. We report two cases in which recovery followed spontaneous drainage into the stomach. A 75-year-old woman with biliary pancreatitis and a 63-year-old man with ethanol-induced pancreatitis both developed pancreatic abscess, diagnosed by computed tomography scans and ultrasound. The spontaneous gastric fistula was heralded by a large emesis of purulent and necrotic material in one case and copious nasogastric tube secretions of a similar material in the other. Defervescence was immediate, and both patients went on to complete recovery without any further interventions. Contrast studies showed the fistulae. It is concluded that in the event that a pancreatic pseudocyst spontaneously drains into the stomach a 'wait and see' policy should be adopted, and a favorable outcome can be expected.     

Diagnostic evaluation and aggressive surgical approach in bleeding pseudoaneurysms associated with pancreatic pseudocysts

Hemorrhage is an uncommon but serious complication of pancreatic pseudocysts. When gastrointestinal bleeding or intra-abdominal hemorrhage is associated with a pancreatic pseudocyst and the usual sources of bleeding are not detected by endoscopy, the rupture of a pseudoaneurysm inside the pseudocyst should be suspected. We present 13 cases, 11 associated with chronic and 2 with late complications after acute necrotizing pancreatitis. On the basis of sonographic findings, bleeding site was suspected in 8 of 11 patients (73%). Computed tomography (CT) was performed on 10, and bleeding was suspected in 8 (80%). The pseudoaneurysm itself was detected by CT in one and by ultrasonography in none. Visceral angiography was performed on five patients, and the pseudoaneurysm was evident in all. External drainage with arterial ligation was done as a primary operation in five patients; four of them later underwent pancreatic resection because of rebleeding. In eight cases pancreatic resection was the initial operation; none of these patients continued to bleed or needed reoperation because of the same pseudoaneurysm. There were no intraoperative deaths, but one patient died postoperatively. Aggressive diagnostic evaluation and surgical approach are associated with a reduction in mortality and morbidity in this serious complication of pancreatic pseudocysts.     

Massive intraperitoneal hemorrhage from a pancreatic pseudocyst

Massive bleeding from a pancreatic pseudocyst is a rare condition that poses a diagnostic and therapeutic challenge. A 36-yr-old woman presented with acute pancreatitis due to gallstones. Twenty-two days later, she developed severe abdominal pain and hypotension. CT scan revealed hemorrhage into a pancreatic pseudocyst and a large amount of free blood in the peritoneal cavity. At laparotomy, 8 L of blood was evacuated from the peritoneal cavity and 14 units of blood were transfused. The gastroduodenal artery was found to be the cause of the bleeding and was undersewn. A pancreatic necrosectomy was performed and the cavity was packed. The packs were removed the following day. Postoperatively, pancreatic collections were aspirated under ultrasound guidance on three occasions. She was discharged 50 days after admission and had an open cholecystectomy 1 month later. She remains well 1 yr after surgery.     

Pancreatic pseudocyst rupture into the renal collecting system

Pseudocyst formation is a well-recognized complication of pancreatitis. Involvement of a pseudocyst with the kidney is rare. We report an unusual case of a pancreatic pseudocyst with rupture into the renal collecting system. The surgical management of this problem is described and the world-wide experience is reviewed briefly.     

The role of surgery in pancreatic pseudocyst

BACKGROUND/AIMS: Surgery has been the only option available for many years for treating pseudocyst of the pancreas. Recently, new methods, such as percutaneous drainage, endoscopic transenteric drainage and transpapillary drainage, began to be used for treatment of the pseudocyst. But we have to agree that no single technique offers the desired combination of 100% success and no complications. We'd like to present our surgical experience in the past 14 years. METHODOLOGY: A total of 22 patients were treated for pancreatic pseudocyst (PP) in our departments in Dalin and Hualien Tzu-Chi General Hospital within the last 14 years. They were retrospectively reviewed and followed up until recently. RESULTS: There were 14 (63.6%) males and 8 (36.4%) females aged between 15 and 79 years old (mean age 38.2 years). Dominating symptoms in most patients were epigastric pain, palpable mass, nausea, vomiting, fever and leukocytosis, and persistent elevation of serum amylase. Imaging studies, such as ultrasound, computed tomography (CT) scan, and endoscopic retrograde cholangiopancreatography (ERCP), were helpful in establishing diagnosis. In addition to symptomatic persistent large (>6cm) pseudocyst, various types of complication including infection, gastrointestinal (GI) obstruction, rupture into GI tract, peritonitis, GI bleeding, internal bleeding, and pancreatic ascites were indications for surgery in our cases. Operative procedures composed of external drainage (ED, 9 cases), internal drainage using cystojejunostomy (CJ, 4 cases) and cystogastrostomy (CG, 8 cases), and distal pancreatectomy (1 case). Ten complications (45.5%) included recurrence of cyst (1 in-ED and 1 in CJ), recurrence with pancreaticopleural fistula (1 in ED), colon perforation (1 in ED), delayed massive bleeding (1 in CG), pancreatic fistula (3 in ED), pancreatic abscess (1 in CJ) and persistent pain (1 in CG). Reoperation was needed to check bleeding (1 in CG) and proximal colostomy for colon injury (1 in ED). A case received CJ for recurrence of pseudocyst 9 years later (1 in CJ). Percutaneous drainage with wide bore tube was effective for pancreatic abscess (1 in CJ) and transpapillary drainage with stent was used to relieve pleural effusion with respiratory failure (1 in ED). No mortality occurred in this series. CONCLUSIONS: We believe that surgery, though without flaws, still plays an important role in the management of selected cases of pseudocyst of the pancreas. Surgical intervention, endoscopic drainage, and percutaneous drainage were complementary rather than conflicting alternatives both for the simple and complicated pseudocysts.     

Should anticoagulants be administered for portal vein thrombosis associated with acute pancreatitis?

Venous complications in patients with acute pancreatitis typically occur as a form of splenic, portal, or superior mesenteric vein thrombosis and have been detected more frequently in recent reports. Although a well-organized protocol for the treatment of venous thrombosis has not been established, anticoagulation therapy is commonly recommended. A 73-year-old man was diagnosed with acute progressive portal vein thrombosis associated with acute pancreatitis. After one month of anticoagulation therapy, the patient developed severe hematemesis. With endoscopy and an abdominal computed tomography scan, hemorrhages in the pancreatic pseudocyst, which was ruptured into the duodenal bulb, were confirmed. After conservative treatment, the patient was stabilized. While the rupture of a pseudocyst into the surrounding viscera is a well-known phenomenon, spontaneous rupture into the duodenum is rare. Moreover, no reports of upper gastrointestinal bleeding caused by pseudocyst rupture in patients under anticoagulation therapy for venous thrombosis associated with acute pancreatitis have been published. Herein, we report a unique case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum, which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis.     

A case of the ruptured splenic artery aneurysm treated with transcatheter embolization]

Splenic artery aneurysms are the most common visceral artery aneurysms, which are usually found incidentally. The most common complication of splenic artery aneurysms is spontaneous rupture into the peritoneal cavity, which leads to acute peritonitis and shock. Less commonly, it may rupture directly into the stomach, small bowel or pancreatic duct and may present with acute gastrointestinal hemorrhage. We report a rare case of the ruptured splenic artery aneurysm, presenting as acute massive hematochezia which was treated with transcatheter embolization.     

Operative treatment of pancreatico-bronchial fistula

Background

Pancreatico-bronchial fistulas are a rare complication of acute or chronic pancreatitis. Both conservative and surgical management have been described previously.

Case outline

The management of a 68-year-old woman with acute pancreatitis complicated by a pancreatico-bronchial fistula was reviewed. CT scanning and magnetic resonance cholangio-pancreatography demonstrated a pancreatic pseudocyst with extension into the posterior mediastinum and right pleura. Despite conservative management as well as ERCP with pancreatic stent insertion, the fistula failed to resolve. Successful management of this difficult problem was achieved with distal pancreatectomy and intercostal drainage.

Discussion

Pancreatico-bronchial fistulas may be managed conservatively, but there should be a low threshold for surgical intervention if endoscopic measures fail.     

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.     

A case of splenic pseudocyst difficult to differentiate from splenic lymphangioma]

Splenic pseudocyst is a rare complication of abdominal trauma. Although it is rare, splenic pseudocyst is well-documented in the literature. According to the current classification, approximately 30% of all splenic cysts or pseudocysts result from direct abdominal trauma. In addition, chronic pancreatitis leads to change of nearby organs with possible acute and chronic complications including splenic lesions. This unusual complication can occur in both emergent and non-emergent conditions. The useful diagnostic procedures to assess intrasplenic pseudocyst are sonogram, CT scan, splenic scan, and occasionally angiography. However, definite diagnosis of pseudocyst is possible only after splenectomy when the absence of epithelial lining is confirmed histologically. Splenic pseudocyst requires surgical resection. We experienced a 31-year-old man who confirmed of warmness in the left side of back with left upper quadrant abdominal pain for several months. First impression was splenic lymphangioma based on CT scan and sonogram finding. Splenectomy was performed. Microscopic examination revealed splenic pseudocyst with fibrous capsule without epithelial lining.     

Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis

Acute mediastinitis is a fatal disease that usually originates from esophageal perforation and surgical infection. Rare cases of descending necrotizing mediastinitis can occur following oral cavity and pharynx infection or can be a complication of pancreatitis. The most common thoracic complications of pancreatic disease are reactive pleural effusion and pneumonia, while rare complications include thoracic conditions, such as pancreaticopleural fistula with massive pleural effusion or hemothorax and extension of pseudocyst into the mediastinum. There have been no reports of acute mediastinitis originating from pancreatitis in South Korea. In this report, we present the case of a 50-year-old female suffering from acute mediastinitis with pleural effusion arising from recurrent pancreatitis that improved after surgical intervention.     

A case of mediastinal pancreatic pseudocyst with hemoptysis successfully treated with total parenteral nutrition]

A 51-year-old man with chronic alcohol-related pancreatitis was admitted to our hospital complaining of hemoptysis. A chest X-ray film revealed a ground-glass opacity in the left lower lung field and a bronchoscopic examination revealed bleeding from the left lower lobe bronchus. Chest multi detector-row CT demonstrated a cystic mediastinal mass along the esophagus from the pancreatic tail reaching the carina. No pleural effusion was found. Based on the clinical and radiographic features, we diagnosed mediastinal pancreatic pseudocyst. After four weeks of the treatment of pancreatitis with total parenteral nutrition, hemoptysis was disappeared and the serum amylase level normalyzed. The follow-up CT scan showed that the cystic mediastinal mass had disappeared completely. Mediastinal pancreatic pseudocyst accompanied by hemoptysis is very rare. We suggest that mediastinal pancreatic pseudocyst also should be considered in the differential diagnosis of alcoholics with hemoptysis.     

Intracystic arteries in a chronic pancreatic pseudocyst

Background

An enlarging pancreatic pseudocyst can incorporate adjacent vessels into its wall, leading to pseudoaneurysm formation in the presence of proteolytic enzymes. Intact arteries running through the cyst cavity are very rare, however.

Case outline

A 54-year-old man with a chronic pancreatic pseudocyst (15 cm diameter) underwent internal drainage by means of cystjejunostomy Roux-en-Y. Two large pulsating arteries running through the cyst cavity were identified as the middle colic artery and one of its branches. Temporary clamping of the transcystic arteries revealed no signs of ischaemia in the transverse colon, so the vessels were ligated and the cystjejunostomy completed. The patient remains well one year later.

Discussion

Bleeding following internal drainage procedures carries a higher mortality rate than spontaneous bleeding in chronic pancreatic pseudocysts but is easier to prevent.This case highlights the importance of thorough exploration of the pseudocyst to identify any vessels in its cavity or wall.