|Year : 2014 | Volume
| Issue : 2 | Page : 151-154
Pseudopancreatic cyst invasion into spleen: Case report and review
Sunder Goyal1, Snigdha Goyal2, Mohinder Kumar Garg1, Uma Garg3
1 Department of Surgery, BPS Government Medical College for Women, Khanpur Kalan, Sonipat, Haryana, India
2 Department of Pathology, Dr. RML Postgraduate Institute of Medical Sciences, New Delhi, India
3 Department of ENT, BPS Government Medical College for Women, Khanpur Kalan, Sonipat, Haryana, India
|Date of Web Publication||11-Aug-2014|
Department of Surgery, BPS Government Medical College for Women, Khanpur Kalan, Sonipat, Haryana
Source of Support: None, Conflict of Interest: None
Splenic parenchymal complications in pancreatitis are uncommon and these vary from invasion of pseudopancreatic cysts into spleen to hemorrhages, infarctions and splenic rupture. Spleen is prone to complications in both acute and chronic pancreatitis due to the anatomical relation of splenic hilum with the tail of pancreas. As clinical picture is non-specific, a high index of suspicion is mandatory for early detection to avoid shattering complications. Conservative management is feasible in patients with small and resolving pseudocysts of pancreas as well as of spleen. Surgery is a treatment of choice for large non-resolving and complicated cyst. We present a 26-year-male with huge pseudopancreatic cyst, which invaded into spleen. Patient was operated by open technique. The case is being presented because of uncommon occurrence along with review of the literature regarding the pre-operative evaluation and various treatment options
Keywords: Pancreatitis, pseudopancreatic cyst, spleen
|How to cite this article:|
Goyal S, Goyal S, Garg MK, Garg U. Pseudopancreatic cyst invasion into spleen: Case report and review. J Mahatma Gandhi Inst Med Sci 2014;19:151-4
|How to cite this URL:|
Goyal S, Goyal S, Garg MK, Garg U. Pseudopancreatic cyst invasion into spleen: Case report and review. J Mahatma Gandhi Inst Med Sci [serial online] 2014 [cited 2020 Jul 15];19:151-4. Available from: http://www.jmgims.co.in/text.asp?2014/19/2/151/138443
| Introduction|| |
Pseudopancreatic cyst is a common complication of pancreatitis. It can leak or invade into adjacent tissues like gastro-hepatic ligament,  liver due to lytic activity of enzymes released during pancreatitis. Rarely cyst can travel to the neck, mediastinum, chest cavity and scrotum.  The spleen, although very close to the pancreas, is rarely involved in this process and about 50 cases have been reported so far.  The spleen is at risk due to inflammation of the tail of the pancreas because of the close proximity with the splenic hilum. The splenic complications consist of perisplenic/intrasplenic pseudocysts, subcapsular hematomas, intrasplenic hemorrhage, splenic infarction and splenic rupture. Pseudopancreatic cyst invading into splenic parenchyma is uncommon and we present such a case in a 26-year-old male.
| Case Report|| |
A 26-year-old male patient presented in an emergency with severe pain abdomen with radiation to back and he gave a history of chronic alcoholism. On examination, there was pallor, hypotension, fever and tachycardia. Abdomen was tender around umbilicus. Total leucocyte count (19000/mm 3 ) and serum amylase (900 IU/l) were very high. A clinical diagnosis of acute pancreatitis was made, which was confirmed on computed tomography (CT) scan. Whole pancreas was swollen and duct and the rest of pancreas was normal. Patient was managed conservatively with antibiotic to prevent secondary infection and fluids. He got relief and was discharged on request.
After 1 month, patient was re-admitted with a lump in epigastrium. On examination, lump was 8 cm × 10 cm in size, firm in consistency. CT scan revealed a pancreatic pseudocyst of body and tail. Patient was treated conservatively and was advised to come for surgery after maturation of the cyst wall (3 months).
At the time of third admission patient presented with a bigger lump in epigastrium extending into left hypochondrium with mild pain radiating to left shoulder. Contrast enhanced CT (CECT) showed huge pancreatic pseudocyst invading into splenic parenchyma. Both cysts were having a wide communication [Figure 1] and [Figure 2]. Surgery (cystogastrostomy + splenectomy) was planned. Cystogastrostomy was done first and we were able to drain both cysts through the cysto-gastrostomy opening as both cysts were having a wide communication [Figure 3]. The amylase level in the cystic fluid was 22012 IU/l, Postoperative USG revealed residual spleenic tissue with residual cystic fluid [Figure 4]. Post-operative period was uneventful.
|Figure 1: Contrast enhanced computed tomography showing pancreatic and splenic pseudocyst with compressed splenic tissue|
Click here to view
|Figure 2: Contrast enhanced computed tomography showing pancreatic pseudocyst communicating with splenic pseudocyst|
Click here to view
|Figure 4: Ultrasonography showing splenic tissue with residual cystic fluid|
Click here to view
| Discussion|| |
Pseudopancreatic cyst due to acute pancreatitis is a collection of inflammatory exudate, which is surrounded by fibrous or granulation tissue only and are caused by a blockage or disruption of the pancreatic duct.
The incidence of pseudocyst extension into the spleen is around 1%. Splenic pseudocysts, sub-capsular hematoma and splenic rupture are more common in patients with chronic pancreatitis, , whereas splenic infarcts and subcapsular hemorrhage happen mostly in acute pancreatitis. Splenic complications in chronic pancreatitis are more common in males (as in our case) and are associated with high morbidity (79%) and mortality (8%).
Several mechanisms have been proposed for the intrasplenic pseudopancreatic cyst invasion. Pancreas tail and splenic vessels are the contents of splenorenal ligament. Anterior peritoneal layer of splenorenal ligament is in continuity with splenic capsule. The pancreatic enzymes released during inflammation or collected fluid (pseudocyst of tail/body) of pancreas can travel to spleen by dissecting postero-laterally along the splenic vessels and thus gain access to splenic parenchyma and result in intrasplenic (splenic pseudocyst) or perisplenic collection.
Pancreatic enzymes can also erode the splenic capsule directly and thus results in isolated splenic pseudocyst. Pseudocyst of spleen can also develop due to pancreatitis of ectopic pancreatic tissue in spleen.
The splenic parenchymal pseudocyst formed due to invasion of pseudopancreatic cyst is mostly isolated and separate entity. Rarely they communicate between each other (as in our case).
Mostly clinical features of splenic complications due to pancreatitis are non-specific and patients can present with pain in the left upper quadrant, referred to the left shoulder or with mass in a left upper quadrant (as in our case). Fever with tachycardia along with leucocytosis may occur in more than half of these patients. , In few cases, there may be sympathetic left sided pleural effusion.
Contrast enhanced helical computerized tomography (CT) scan is important imaging tool for diagnosis. However, most important is a high index of suspicion in mind about this clinical entity as there is no specific clinical picture of splenic pseudocyst due to invasion.  Magnetic resonance imaging scan has got better ability to clearly define different soft-tissue constituents and can detect vascular complications such as pseudoaneurysms and venous thrombosis.
Management of patients depends upon the size and on communication between splenic and pancreatic pseudocysts. Ideal treatment of small splenic parenchymal pseudocysts is by conservative approach and of large cyst is by endoscopic drainage (if the cyst is in close contact with stomach), percutaneous catheter drainage, or splenectomy (open or laparoscopic).  As there are high incidences of post-splenectomy infection, conservative therapy should be used whenever possible. During the follow-up of conservative therapy, repeated ultrasound is used. Small splenic cyst can regress spontaneously during the conservative therapy. Time for regression varies from 1 week to 4 months. The role of percutaneous drainage of these lesions is still doubtful. ,
Endoscopic drainage of pseudocysts is becoming the preferred therapeutic approach as it is less invasive, with minimum morbidity and no mortality. Endoscopic drainage depends on the anatomy and topography of the pseudocyst and can be done either transpapillary (via endoscopic retrograde cholangiopancreatography) or transmurally. Transpapillary drainage is safer and more effective than transmural drainage, but cyst should communicate with the pancreatic duct. In this technique a guide wire is passed in duct over which stenting done through the pancreatic duct to the pseudocyst. The success rate is about 80%. The recurrence rate is 10-14%. Common complications of stenting are exacerbation of pancreatitis (approximately 13%), stent occlusion or chronic pancreatitis.
Endoscopic transmural drainage is especially useful in situations where a complete cut-off of the pancreatic duct prevents endoscopic transpapillary drainage. This involves performing an endoscopy and finding a bulge within the wall of the stomach or duodenum caused by compression of the pseudocyst. The cyst is generally entered using a needle knife to cut through the gastric or duodenum wall. The pigtail stents are placed through the opening between cyst and viscera. For endoscopic pancreatic pseudocyst drainage, wall of pseudocyst should be mature, there should be no pseudoaneurysms, portal hypertension and gastric varices, cyst should be in close contact of viscera, pancreatography should be done first and always confirm the diagnosis of pseudocyst.  The method has an 82-89% success rate in expert hands. The recurrent rate is 6-18%. The complication rate is 20%, with the most feared complication being bleeding.
The hemodynamically unstable patient with splenic rupture or hemoperitoneum will require emergency laparotomy and either splenectomy or distal pancreatosplenectomy, which may potentially reduce the risk of pancreatic leak or fistula formation.  In patients with large splenic parenchymal lesions or evidence of perisplenic bleeding, close monitoring is necessary and elective or pre-operative splenic artery embolization may be desirable. A modified therapeutic approach involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and surgeon should be considered in all cases. 
Post-splenectomy infection syndrome comprises fulminating bacteremia, disseminated intravascular coagulation, multiple organs failure, severe hypoglycemia and rapid death. Its incidence is about 0.9-60% and mortality rate is about 50%.
In our case, patient presented with huge pancreatic pseudocyst, which invaded into splenic parenchyma and both had a wide communication. Cysto-gastrostomy was done to drain the pseudopancreatic cyst and both cysts got drained simultaneously through one hole (due to wide connection). Post-operative USG showed well-drained both cysts and a fair amount of splenic tissue to save the patient from the post-splenectomy syndrome.
| Conclusion|| |
Pseudopancreatic cyst invasion in splenic parenchyma is uncommon. Symptomatology is non-specific and can vary from left upper quadrant pain to that of an hemodynamically unstable patient. High index of suspicion and serial ultrasound can pick up splenic parenchymal involvement early. A tailored therapeutic approach involving multidisciplinary team of therapeutic endoscopist, interventional radiologist and surgeon should be considered.
| References|| |
|1.||Goyal S, Raju R, Yadav S. Pancreatic pseudocyst of gastrohepatic ligament: A case report and review of management. JOP 2012;13:439-42. |
|2.||Accetta P, Accetta I, Accetta R, Campos KB, Rodrigues MF. Pancreatic pseudocyst with splenic involvement. Case report. Rev Col Bras Cir 2010;37:457-9. |
|3.||Thompson JE Jr, Ashley SW. Subcapsular hematoma of the spleen associated with acute pancreatitis. Surgery 1997;121:231-3. |
|4.||Rypens F, Devière J, Zalcman M, Braudé P, Van de Stadt J, Struyven J, et al. Splenic parenchymal complications of pancreatitis: CT findings and natural history. J Comput Assist Tomogr 1997;21:89-93. |
|5.||Heider R, Behrns KE. Pancreatic pseudocysts complicated by splenic parenchymal involvement: Results of operative and percutaneous management. Pancreas 2001;23:20-5. |
|6.||Chak A. Endosonographic-guided therapy of pancreatic pseudocysts. Gastrointest Endosc 2000;52:S23-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]