3033 Acute Pancreatitis Complicated by Pancreatic Pseudocyst and Splenic Hematoma, Management Considerations

Abstract

INTRODUCTION: Pancreatic duct disruption is a known complication of pancreatitis which leads to the formation of pancreatic pseudocysts, pancreatic ascites, and high amylase pleural effusions. Pancreatic pseudocysts migrate along with the pancreatic tissue and rupture either into surrounding organs or into the free peritoneal cavity. Splenic complications of pancreatitis are rare and include splenic vein thrombosis, splenic artery rupture, splenic rupture or infarction, and splenic hematoma. CASE DESCRIPTION/METHODS: 39 y/o alcoholic male admitted for acute pancreatitis. Imaging revealed pseudocysts and ascites. Initially, he improved with supportive care but abdominal pain recurred owing to splenic rupture with resultant splenic hematoma. Splenic artery coiling was employed to stop bleeding. He returned for recurrent abdominal pain and new chest pain with interval increase in size of pseudocyst and interval development of pleural effusion. EUS revealed a multiloculated pancreatic pseudocyst, as well as pancreatic duct disruption. Transgastric drainage of the pseudocyst was performed with an Axios stent. Repeat endoscopy at interval showed complete resolution of the cyst. DISCUSSION: Studies estimate the incidence of pancreatic pseudocyst rupture into the spleen at a rate of up to 1.1% of patients with acute pancreatitis. Another study of patients with chronic pancreatitis reports splenic pseudocyst as the most common lesion, followed by splenic rupture and hematoma. A more recent study of 500 men with chronic alcoholic pancreatitis found that only 2.2% develop splenic complications with intrasplenic pseudocyst being the most common lesion, followed by splenic rupture and subcapsular hematoma. Findings associated with the highest risk of developing splenic complications included pancreatic tail necrosis, distal pseudocyst, or splenic vein occlusion. Previously, the mainstay of treatment for splenic hematoma was splenectomy with distal pancreatectomy. However, with the advent of advanced endoscopic procedures, patients are safely managed with splenic artery embolizationand EUS guided pancreaticogastrostomy or percutaneous drainage. Endoscopic drainage and percutaneous drainage of symptomatic pseudocysts are preferred to surgical management. Furthermore, recent reviews show that endoscopic drainage is superior to percutaneous drainage with lower rates of reintervention, shorter hospital stays, and need for less follow-up imaging.

Akute nekrotisierende Pankreatitis mit hämorrhagischem Schock bei sekundärer Milzruptur: Ein Fallbericht und Literaturübersicht

“…Eine Literaturrecherche nach den Schlüsselwörtern „pancreatitis“, „splenic rupture“ und „splenic hematoma“ in Pubmed, MEDLINE und Google Scholar von Januar 2012 bis August 2022 ergab 21 publizierte Fallberichte, welche sich mit dem Thema beschäftigt haben 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 . Hierbei erfolgte in den meisten Fällen eine offene Laparotomie mit Splenektomie.…”

“…Hierbei erfolgte in den meisten Fällen eine offene Laparotomie mit Splenektomie. Lediglich 3 weitere Fälle wurden ebenfalls radiologisch interventionell embolisiert 8 11 20 . In einem Fallbericht sistierte die Blutung spontan und die Milz wurde in situ belassen 6 .…”

“…In einem Fallbericht sistierte die Blutung spontan und die Milz wurde in situ belassen [6]. Nur ein Fallbericht in Abstract Format skizziert die von uns gewählte Sequenz aus funktioneller Splenektomie mittels radiologischer Embolisation und endoskopischer Drainage eines pankreatitischen Verhaltes [11]. ▶ Abb.…”