Introduction
Current guidelines on the management of pancreatic pseudocysts in chronic pancreatitis strongly recommend intervention if they become symptomatic or develop complications. However, there is no clear consensus regarding the management of asymptomatic pseudocysts >5cm (1-3). Complications include rupture, haemorrhage, gastric outlet obstruction and infection (1). We present a case of an asymptomatic 5cm pancreatic pseudocyst in which all four of these complications occurred.
Case
A 65-year-old male with a history of chronic pancreatitis and 5cm pancreatic head pseudocyst under surveillance was admitted to hospital with a superficial femoral artery occlusion. A computed tomography (CT) angiography of the aorta and lower extremities incidentally found the pseudocyst had ruptured into the peritoneal cavity and eroded into the pancreaticoduodenal artery. He underwent urgent embolisation by interventional radiology and stabilised without needing surgical intervention.
Six days later, the patient developed vomiting and abdominal pain, and a repeat CT showed gastric outlet obstruction from the pseudocyst. After a few days of decompression with a nasogastric tube, an endoscopy revealed the pseudocyst was spontaneously draining into the duodenum via a pseudocysto-duodenal fistula.
Another CT was obtained weeks later to investigate persistent fevers with no clear source of infection and no improvement despite broad-spectrum intravenous antibiotics. The original pseudocyst had reduced in size, but two communicating subcapsular liver collections with thickened walls and loculations suggesting infection were visualised. A percutaneous drain inserted by interventional radiology drained frank pus. While fluid culture did not grow any organisms, 16s RNA PCR detected Enterobacter. The drain was removed after two weeks, and the patient was eventually discharged home.
Conclusion
Pseudocyst diameter <4cm is the only independent prognostic factor for spontaneous resolution (4). An early natural history study found that 40% of untreated pseudocysts will develop complications, with some studies reporting complication rates of up to 67% if persisting beyond 12 weeks (2,5). Current guidelines do not provide clear recommendations for management of asymptomatic pseudocysts like this case (1-3). Given the recent advancements in endoscopic techniques and potential complications of untreated pseudocysts, we suggest review of the literature and updated recommendations on the management of asymptomatic pseudocysts >5cm.