57 years old male chronic
alcoholic for last 30 years presented with c/o pain abdomen, vomiting for last 20 days. Pain abdomen was constant dull aching mainly in epigastric
region. Vomiting used to occur just after intake of meal and it did not contain
altered or fresh blood. He also had 1 episode of melena 15 days back. Similar
type of abdominal pain was present 1 year back for which he required
hospitalisation for 4 days. On examination there was pallor, palpable diffuse
lump in the epigastrium. There was no lymphadenopathy, icterus, cyanosis,
hepatosplenomegaly. On evaluation he was found to have anemia (Hb-7.2), large
pseudocyst (22 cms by 10 cms) in pancreas compressing the stomach from
posterior side as seen in UGI endoscopy. There was also a duodenal ulcer in D1.
A diagnosis of acute on chronic pancreatitis complicated by pseudocyst
formation, etiology being alcohol, was made. For duodenal ulcer he we started
on proton pump inhibitors in double strength. He also received i/v fluids,
analgesics and anti-emetics. Liver function and renal function tests were
normal. CECT abdomen showed hyperdense content in the pancreatic pseudocyst causing
cyst in cyst appearance so possibility of pseudoaneurysmal bleed was kept, but
CT angiogram did not reveal any sign of pseudoaneurysm. He received 3 units of
blood transfusion in the hospital following which his haemoglobin raised from 7.2
to 9.7. Then cystogastrostomy was done for the drainage of large cyst which was
eminent to rupture. Patient recovered uneventfully thereafter.
TAKE HOME MESSAGE-
1. Most common cause of acute
pancreatitis is Gall stone and of chronic pancreatitis is alcohol.
2. Incidence of pseudocyst in
acute pancreatitis varies from 5% to 20%.
3. Pseudoaneurysm formation
and subsequent rupture is one of the fearsome complication.
4. Endoscopic drainage is
effective method of management of pancreatic pseudocyst. Most commonly used technique
is gastrocystostomy which is performed endoscopically.
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