Original case by Brandon Fainstad, MD
Edits and graphics by Yilin Zhang, MD
- Recognize different management options for patients with peripancreatic fluid collections and associated complications
34 year old man presents to the ED with fever and abdominal pain. The abdominal pain is episodic, worse after meals, initially epigastrium but now most intense in the LLQ. This pain has been worsening over the past month. The fever first developed three days ago. He denies any change in his stools, his urine output has been low the past couple days but no dysuria or hematuria. He has a history of severe necrotizing EtOH pancreatitis 1 year prior complicated by a self resolving pseudocyst (as of 10 months ago) and chronic intermittent abdominal pain and insulin dependent diabetes. His medications include gabapentin and insulin. He denies any ongoing EtOH use.
On exam he is febrile 38.4C, HR 130, BP 110/70 and SpO2 98% on RA. He is uncomfortable and diaphoretic. His abdomen is diffusely tender, but most severe in the LLQ with voluntary guarding but no rebound tenderness. Labs are significant for Cr 0.8, WBC 15k, Hct 42%, lipase 11, INR 1.2 with otherwise normal LFTs.
CT A/P #1
What options are there to manage a pancreatic pseudocyst?
Pseudocysts can be managed with expectant management or with drainage. Conservative management can be considered initially as >40% pseudocysts resolve spontaneously. Patients with severe pain, nonresolving infected pseudocyst or compression of adjacent structures should be considered for drainage.
Drainage can be:
- Surgical – cystogastrotomy
- Endoscopic – endoscopic transenteric drainage
GI was concerned that the fluid collection had not fully matured and that he would be at risk of rupturing during drainage so he was treated with IV Zosyn for suspected superinfected pancreatic pseudocyst. His fever, tachycardia and pain resolved with antibiotic therapy and he was dischaged on 5 days of moxifloxacin and pancrealipase.
Unfortunately, he returned to the ER 4 weeks later with a week of increasing LLQ abdominal pain, fevers, rigors and ongoing weight loss.
CT A/P #2
Repeat imaging revealed necrotic pancreatitis with a slightly enlarged peri-pancreatic fluid collections extending into the LLQ with surrounding inflammation.
He was admitted to the general surgery service. GI and general surgery both felt this collection was high risk for endoscopic or surgical drainage but was well located for percutaneous drainage given its extension into the LLQ. He was initiated on IV meropenem and underwent 2 IR placed drains. He was eventually narrowed to flagyl and levo to complete a 10 day course and discharged 5 days into therapy tolerating a diet without significant ongoing symptoms.
At 6 weeks, he underwent a follow-up CT.
CT A/P #3
Repeat imaging showed resolution of peripancreatic fluid collections (IR drains still in place on CT above). He underwent removal of IR placed drains.
TAKE HOME POINTS:
- Peripancreatic fluid collections mature ~ 4-8 weeks after initial episode of pancreatitis.
- They can be managed expectantly with serial imaging as ~40% of patients have spontaneous resolution.
- For patients who require drainage, there are surgical, endoscopic and percutaneous options for drainage.