S3550 Idiopathic Pancreatitis With Recurrent Pseudocysts and Stent Obstruction: A Case Report

Introduction: Pancreatic pseudocysts are fluid collections that can form after pancreatitis or pancreatic injury. They can cause local compression in addition to hemorrhage, rupture, or infection. Although previously surgically managed, endoscopic treatment has emerged as a treatment modality with more favorable safety profiles. This case highlights recurrent pseudocysts in a patient with idiopathic chronic pancreatitis after multiple interventions. Case Description/Methods: A 49-year-old man with a history of idiopathic chronic pancreatitis complicated by pseudocysts and numerous endoscopic interventions presented to the emergency department with nausea, vomiting, and abdominal pain. In his last procedure, a 2.4 cm body pseudocyst obstructing the main ductal stent was treated with stent exchange, and other small collections in the tail were noted. There was tenderness with guarding in all quadrants on physical exam and serum lipase was elevated at 116. Computed tomography scan revealed severe tail pancreatitis with distal pancreatic duct stent migration and malposition. Magnetic resonance cholangiopancreatography (MRCP) revealed multiloculated fluid collection in the tail with the largest 5.6 × 3.1 × 4.6 cm suspicious for acute pancreatitis and pseudocysts. The patient was started on pain control, antiemetics and fluids. Endoscopic retrograde cholangiopancreatography (ERCP) revealed significant contrast extravasation into pseudocyst and ductal stricture. One stent was then placed into the dorsal pancreatic duct. The patient’s pain improved after his procedure and his diet was advanced. He was then discharged in stable condition. Discussion: Endoscopic treatment of pancreatic pseudocysts is common, with specific treatment options depending on cyst location and complications. For pseudocysts due to acute pancreatitis, treatment is largely successful. However, the association with chronic pancreatitis, multiple cysts, and pancreatic tail location correlate with recurrence and were all factors present in this case. Pancreatic ductal strictures also increase recurrence risk which occurred in this patient as well. For such patients, providers should not only obtain imaging, but also closely monitor clinical symptoms and lab tests for timely diagnosis and management of recurrent pseudocysts.