Context: Pseudocysts are a common complication of acute and chronic pancreatitis. These are usually located within the pancreas but they can occur at other sites as well, including the mediastinum, neck, pelvis and rarely in the liver as in our case. The diagnosis of intrahepatic pancreatic pseudocyst relies on the demonstration of a high amylase level in the sampled cystic fluid in the absence of infection or neoplasm. Case report: A 60-year-old man with a history of chronic pancreatitis presents with a clinical and laboratory picture suggestive of acute exacerbation of his pancreatitis. A computed tomogram (CT) scan of the abdomen revealed a pancreatic pseudocyst and a cystic lesion involving both lobes of the liver. CT diagnostic aspiration of the intrahepatic cyst revealed high amylase level (greater than 20,000 U/L). The cyst was treated with percutaneous drainage with complete resolution of the cyst. Conclusion: In the setting of pancreatitis, intrahepatic pancreatic pseudocyst should be considered in the differential diagnosis of cystic lesion of the liver.

Pancreatic pseudocysts are a complication of acute or chronic pancreatitis or result from blunt trauma to the pancreas. It is a localized fluid collection around the pancreas surrounded by a wall of fibrous tissue or inflammation. We present a case of a 56-years old male who presented with abdominal pain and sepsis due to spontaneous rupture of the hemorrhagic pancreatic cyst into the peritoneal cavity and spleen. 56-years old male with medical history of gastroesophageal reflux disease presented with epigastric and left upper quadrant intermittent abdominal pain. Patient denied fever, chills, nausea, and vomiting, family history of pancreatic cancer, anticoagulation use, gallstones, alcohol intake and prior history of pancreatitis. On admission, vitals were B.P 137/82, Pulse 102, RR 16, O2 saturation 92% on room air. Physical exam was significant for left upper quadrant and epigastric tenderness. Labs were lipase 230, amylase 112, lactate 0.7, wbc 7.0, hemoglobin of 15.2 and triglyceride levels were 189mg/dl. Computed tomography (CT) abdomen showed acute pancreatitis and a 4.5 x 4.4 x 2.8 cm cystic lesion between the tail of the pancreas and splenic hilum. Ultrasound of the abdomen showed normal gallbladder with no evidence of biliary ductal dilatation. Magnetic resonance cholangiopancreatography (MRCP) abdomen showed 4.3 cm walled off, possibly hemorrhagic fluid collection, between the spleen and the pancreas. Patient had normal CA-19 level. Patient was evaluated by general surgery who recommended conservative management with repeat CT in 6 weeks with possible pancreatectomy and removal of mass if not resolved. Patient was readmitted 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, wbc 11.3, hgb 12.1 and lipase 600. Repeat CT scan showed rupture of the hemorrhagic pancreatic cyst with possible extravasation and enlarged spleen with perisplenic and subcapsular blood represent splenic infarcts. Repeat MRCP confirmed CT findings. Patient was planned for splenectomy and distal pancreatectomy. Most pancreatic pseudocysts resolve spontaneously [1]. Bleeding, infection, rupture, pseudoaneurysm, splenic and biliary complications and portal hypertension are some of the complications if left untreated. Hemorrhage into the pancreatic pseudocyst is a rare complication with a reported 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%) [2]. Diagnosis is made by ultrasound, CT scan, MRI or ERCP. Treatment involves either percutaneous drainage, or endoscopic or surgical approach. Spontaneous rupture into the peritoneal cavity is a rare life threatening complication requiring immediate surgical intervention. This case highlights the early recognition of complications of ruptured pancreatic pseudocyst to prevent fatal consequences. References: 1: Lerch MM, Stier A, Wahnschaffe U, Mayerle J: Pancreatic Pseudocysts: Observation, Endoscopic Drainage, or Resection. Deutsches Ärzteblatt International 2009, 106:614-621.10.3238/arztebl.2009.0614. 2: Novacic K1, Vidjak V, Suknaic S, Skopljanac A: Embolization of a large pancreatic pseudoaneurysm converted from pseudocyst (hemorrhagic pseudocyst). JOP 2008, 9:317-21. joplink.net/prev/200805/13.html

Mediastinal pancreatic pseudocyst (MPP) is a rare, but known, complication of both acute and chronic pancreatitis. Most pseudocysts are associated with alcoholic pancreatitis. Recent advances in endoscopic techniques have shown promising results, with reduced chances of infection and recurrence than with percutaneous drainage, but limited availability restricts widespread use. Left gastric artery pseudoaneurysm with mediastinal pseudocyst has not been described in the literature to date. We report a successful resolution of hemorrhagic MPP with embolization of pseudoaneurysm and percutaneous trans-hepatic pseudocyst drainage.