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Pancreatic pseudocyst with hemorrhage into the gastrointestinal tract through the duct of Wirsung
Pancreatic Pseudocyst with Hemorrhage into the Gastrointestinal Tract through the Duct of Wirsung Albert Y. Lam, MD, St. Louis, Missouri Robert S. Bricker, MD,* St. Louis, Missouri
The presentation of pancreatic pseudocyst may be varied and sometimes catastrophic, as exemplified ‘by a recent report of an intrasplenic pancreatic pseudocyst associated with rupture and intraperitoneal hemorrhage [I]. We recently encountered a similar case of an unsuspected pseudocyst that had eroded into the splenic artery and caused massive upper gastrointestinal bleeding in an unusual manner. Case Report A forty-six year old black man was hospitalized with a two week history of pain in the left shoulder and mild abdominal pain. Four years previously, he had been hospitalized for alcoholic pancreatitis and pulmonary tuberculosis. Medical treatment was begun. At the present admission, laboratory test results were unremarkable; however, x-ray study of the chest showed a left subpulmanic effusion. An upper gastrointestinal series suggested anterior displacement of the stomach and an extrinsic defect on the greater curvature. (Figure 1.) While hospitalized, the patient had massive bright red hematemesis. Gastroscopy identified an extrinsic mass on the posterior wall of the stomach but no evidence of a site of bleeding. Celiac angiograms demonstrated pooling of contrast material in the area of the distal splenic artery with free extravasation into the left Fromthe Department
of Surgery, Washington University School of Meditine, St. Louis, Missouri. * present address and address for reprint requests: Albuquerque Surgical Group. 718 Encino Place, Albuquerque, New Mexico 87102.
694
upper quadrant. This was believed to be consistent with a pseudocyst of the pancreas, which had eroded into the splenic artery causing massive bleeding. (Figure 2.) At operation a large cystic mass was identified posterior to the stomach, filling the left upper quadrant and encompassing the spleen. Anterior gastrostomy was made in an attempt to identify possible gastric irritation or penetration from the pseudocyst. Although the stomach was filled with fresh blood clots, no site of hemorrhage was identified in either the stomach or the distal esophagus. The duodenum was explored through a duodenotomy and there was no evidence of a bleeding site. The cyst was then explored through a cystogastrotomy. Because of massive hemorrhage through the cystogastrotomy, the cyst with the spleen and tail of the pancreas was removed to gain control of the presumed site of hemorrhage from the splenic artery. Hemostasis was obtained and a large sump and Penrose drain were placed into the left upper quadrant. The patient’s postoperative course was uneventful, and he was discharged on the twenty-first day.
Comments There have been separate reports of rupture of a pseudocyst into the stomach, duodenum, and common bile duct [2-51, causing massive upper gastrointestinal
bleeding.
However,
the bleeding
of a
pseudocyst into the gastrointestinal tract through the duct of Wirsung has not been reported. In our case,
the findings
at operation
lead to the conclu-
The American Journal of Surgery
Pancreatic
Pseudocyst
with Hemorrhage
Figure 2. Celiac arteriogram showing puddling of contrast medium in area of terminal spienic artery with extra vasation. Figure 1. Barium study showing extrinsic defect on greater curvature of stomach.
sion that there was continuity between the pseudocyst, the pancreatic duct, and the gastrointestinal tract. Such communications are rare since a pseudocyst is usually due to some degree of ductal obstruction; however, communications between pseudocysts and the major or minor pancreatic ducts have been demonstrated. The choices of treatment for a pseudocyst are internal drainage, external drainage, or excision. Although the mortality of excisional therapy is highest, for a pseudocyst that has eroded into a major artery, excision is probably the preferred method of treatment. This allows adequate exposure for control of hemorrhage and removes the source of irritation, which might cause renewed erosion and further hemorrhage if left in place. Moreover, with total excision of the pseudocyst, the recurrence rate (2.5 per cent) is significantly lower than that with either external or internal drainage [6].
Volume 129, June 1975
Summary
A case of massive upper gastrointestinal hemorrhage is presented in which a pancreatic pseudocyst eroded into the splenic artery resulting in intracystic hemorrhage through the duct of Wirsung. Total excision of the pseudocyst, spleen, and tail of the pancreas is recommended. References 1. Warshaw AL, Chesney TM, Evans GW, McCarthy HF: Intrasplenic dissection by pancreatic pseudocyst. N fngl J A&d 287: 72, 1972. 2. Coghill CL: Hemorrhage in pancreatic pseudocysts. Review of literature and report of two cases. Ann Surg 167: 112, 1968. 3. Dalton WE. Lee HM, Williams GM, Hume DM: Pancreatic pseudocyst causing hemobilii and massive gastrointestinal hemorrhage. Am J Surg 120: 106, 1970. 4. Glass RL, Newstedt JR: Hemobilia: an unusual complication of chronic pancreatitis. MO Med 6 1: 854, 1964. 5. Littman R, Pochaczevsky R, Richter R: Spontaneous rupture of a pancreatic pseudocyst into the duodenum. Arch Surg 100: 76, 1970. 6. Balfour JF: Pancreatic pseudocysts: complications and their relation to the timing of treatment. Surg C/in North Am 50: 395.1970.
695
The presentation of pancreatic pseudocyst may be varied and sometimes catastrophic, as exemplified ‘by a recent report of an intrasplenic pancreatic pseudocyst associated with rupture and intraperitoneal hemorrhage [I]. We recently encountered a similar case of an unsuspected pseudocyst that had eroded into the splenic artery and caused massive upper gastrointestinal bleeding in an unusual manner. Case Report A forty-six year old black man was hospitalized with a two week history of pain in the left shoulder and mild abdominal pain. Four years previously, he had been hospitalized for alcoholic pancreatitis and pulmonary tuberculosis. Medical treatment was begun. At the present admission, laboratory test results were unremarkable; however, x-ray study of the chest showed a left subpulmanic effusion. An upper gastrointestinal series suggested anterior displacement of the stomach and an extrinsic defect on the greater curvature. (Figure 1.) While hospitalized, the patient had massive bright red hematemesis. Gastroscopy identified an extrinsic mass on the posterior wall of the stomach but no evidence of a site of bleeding. Celiac angiograms demonstrated pooling of contrast material in the area of the distal splenic artery with free extravasation into the left Fromthe Department
of Surgery, Washington University School of Meditine, St. Louis, Missouri. * present address and address for reprint requests: Albuquerque Surgical Group. 718 Encino Place, Albuquerque, New Mexico 87102.
694
upper quadrant. This was believed to be consistent with a pseudocyst of the pancreas, which had eroded into the splenic artery causing massive bleeding. (Figure 2.) At operation a large cystic mass was identified posterior to the stomach, filling the left upper quadrant and encompassing the spleen. Anterior gastrostomy was made in an attempt to identify possible gastric irritation or penetration from the pseudocyst. Although the stomach was filled with fresh blood clots, no site of hemorrhage was identified in either the stomach or the distal esophagus. The duodenum was explored through a duodenotomy and there was no evidence of a bleeding site. The cyst was then explored through a cystogastrotomy. Because of massive hemorrhage through the cystogastrotomy, the cyst with the spleen and tail of the pancreas was removed to gain control of the presumed site of hemorrhage from the splenic artery. Hemostasis was obtained and a large sump and Penrose drain were placed into the left upper quadrant. The patient’s postoperative course was uneventful, and he was discharged on the twenty-first day.
Comments There have been separate reports of rupture of a pseudocyst into the stomach, duodenum, and common bile duct [2-51, causing massive upper gastrointestinal
bleeding.
However,
the bleeding
of a
pseudocyst into the gastrointestinal tract through the duct of Wirsung has not been reported. In our case,
the findings
at operation
lead to the conclu-
The American Journal of Surgery
Pancreatic
Pseudocyst
with Hemorrhage
Figure 2. Celiac arteriogram showing puddling of contrast medium in area of terminal spienic artery with extra vasation. Figure 1. Barium study showing extrinsic defect on greater curvature of stomach.
sion that there was continuity between the pseudocyst, the pancreatic duct, and the gastrointestinal tract. Such communications are rare since a pseudocyst is usually due to some degree of ductal obstruction; however, communications between pseudocysts and the major or minor pancreatic ducts have been demonstrated. The choices of treatment for a pseudocyst are internal drainage, external drainage, or excision. Although the mortality of excisional therapy is highest, for a pseudocyst that has eroded into a major artery, excision is probably the preferred method of treatment. This allows adequate exposure for control of hemorrhage and removes the source of irritation, which might cause renewed erosion and further hemorrhage if left in place. Moreover, with total excision of the pseudocyst, the recurrence rate (2.5 per cent) is significantly lower than that with either external or internal drainage [6].
Volume 129, June 1975
Summary
A case of massive upper gastrointestinal hemorrhage is presented in which a pancreatic pseudocyst eroded into the splenic artery resulting in intracystic hemorrhage through the duct of Wirsung. Total excision of the pseudocyst, spleen, and tail of the pancreas is recommended. References 1. Warshaw AL, Chesney TM, Evans GW, McCarthy HF: Intrasplenic dissection by pancreatic pseudocyst. N fngl J A&d 287: 72, 1972. 2. Coghill CL: Hemorrhage in pancreatic pseudocysts. Review of literature and report of two cases. Ann Surg 167: 112, 1968. 3. Dalton WE. Lee HM, Williams GM, Hume DM: Pancreatic pseudocyst causing hemobilii and massive gastrointestinal hemorrhage. Am J Surg 120: 106, 1970. 4. Glass RL, Newstedt JR: Hemobilia: an unusual complication of chronic pancreatitis. MO Med 6 1: 854, 1964. 5. Littman R, Pochaczevsky R, Richter R: Spontaneous rupture of a pancreatic pseudocyst into the duodenum. Arch Surg 100: 76, 1970. 6. Balfour JF: Pancreatic pseudocysts: complications and their relation to the timing of treatment. Surg C/in North Am 50: 395.1970.
695