S3458 Giant Hemorrhagic Pancreatic Pseudocyst: A Rare and Dangerous Complication

Introduction: Hemorrhage of a pancreatic pseudocyst is a rare complication of pancreatitis caused by erosion from the arterial wall opposing the pseudocyst, most commonly the splenic artery, and less commonly the gastric artery. It is associated with a high mortality rate between 34-52% and requires emergent intervention. Case Description/Methods: A 26-year-old man with a history of motor vehicle accident 1 year ago complicated by gastrostomy tube and necrotizing biliary pancreatitis with recent outpatient cholecystectomy, presented from outside hospital with abdominal pain, nausea, and non-bloody vomiting for 3 weeks. Computed tomography of the abdomen showed increased size of a complicated intrapancreatic pseudocyst versus walled-off necrosis replacing the body and tail of the pancreas with a questionable hemorrhagic component but no discrete pseudoaneurysm was seen. There was displacement of the stomach with gastric edema and compromise of the portal system, with multiple engorged perigastric collaterals with interposition between the stomach wall. Patient became tachycardic to the 140s, febrile, and hypotensive. Initial hemoglobin of 10.0 gm/dL was repeated and found to be 6.8 gm/dL and mass transfusion protocol was initiated for suspected hemorrhagic shock. Interventional radiology successfully embolized the left gastric artery with gelfoam and coil embolization of the gastroduodenal artery. Later during his course, endoscopic ultrasound showed the 10 cm pancreatic collection with extrinsic compression on gastric body. A cystogastrostomy was performed with placement of a 10 French × 3 cm double pigtail stent with a large interval decrease in the size of the cyst. Patient was subsequently discharge and returned 2 weeks later for removal of the stent without complication. Discussion: This case highlights an emergent complication of pancreatitis, which while rare, bleeding caused by pancreatic pseudocysts is associated with high mortality and morbidity.