S3274 Case Report on Autofistulization of Hemorrhagic Pseudocyst into the Bowel With Loss of Tamponade Effect Triggering Recurrent Aneurysmal Bleeding Into the Pancreatic Cyst

Introduction: Hemorrhagic pancreatic pseudocyst is a rare (2.5%) but serious complication of pancreatitis. Our case highlights the rare occurrence of the aneurysmal bleeding into the pseudocyst as a complication of necrotizing pancreatitis. Bleeding from splenic artery branch aneurysm into the pseudocyst can be asymptomatic initially except laboratory evidence of anemia with acute drop in Hb. Furthermore, combination of the findings including gas within cyst, decreasing size of the cyst along with drop in Hb should warrant immediate investigation to rule out aneurysmal bleeding. We hypothesized that the recurrent bleeding in our patient was secondary to loss of tamponade effect within pseudocyst after spontaneous drainage of the cystic content into the bowel. Case Description/Methods: Sixty-six-year-old woman who was recently diagnosed with necrotizing pancreatitis and hemorrhagic pseudocyst secondary to alcohol use disorder without findings of splenic artery aneurysm on initial dedicated cross-sectional imaging now presented to emergency department after labs revealing anemia with drop in hemoglobin to 5.2 mg/dl. Patient denies symptoms of overt gastrointestinal bleeding, fever or abdominal pain. Repeat computed tomography abdomen with contrast showed decreasing size of poorly complex collection consistent with resolving hemorrhagic pseudocyst at the region of pancreatic tail measuring 6 cm associated with gas bubbles as well as an air-fluid level, raising suspicion of superinfection or fistulization with the adjacent small bowel. Due to this, repeat computed tomography angiogram was planned to rule out underlying aneurysmal bleeding into the cystic cavity given loss of tamponade effect from hematoma within cystic cavity after autofistulization of the cyst into the bowel. While en route to imaging, patient developed hypovolemic shock complicated by transient cardiac arrest. Emergent computed tomography angiography following adequate resuscitation confirmed 3 aneurysms from branches of splenic artery. Successful angiogram with coil embolization was performed. Patient subsequently extubated and discharged home without concern of pseudocyst superinfection. Discussion: Hemorrhagic pancreatic pseudocyst is a rare complication of the necrotizing pancreatitis. Underlying splenic artery related aneurysm should be ruled out especially in patients with low level of Hb or worsening anemia. Decision to perform cystgastrostomy in this setting should be carefully sought to avoid loss of tamponade effects over bleeding aneurysm from cyst content. In this case we deliberately avoided endoscopic ultrasound guided cystgastrostomy due to above reasons.