YAJEM-158825; No of Pages 2

American Journal of Emergency Medicine xxx (xxxx) xxx

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Hemorrhagic pancreatic pseudocyst: A rare complication

Pujitha Kudaravalli, M.B.B.S. a,⁎, Nikita Garg, M.B.B.S. a,
Venkata Satish Pendela, M.D. b, Harvir Singh Gambhir, M.D. a
a
Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, United States of America
b
Department of Internal Medicine, Rochester General Hospital, Rochester, NY 14621, United States of America

a r t i c l e i n f o a b s t r a c t

Article history: Pancreatic pseudocysts are seen both in acute and chronic pancreatitis. Prevalence of pancreatic pseudocyst in
Received 24 January 2020 chronic pancreatitis is 20% to 40% and is most commonly seen in alcoholic chronic pancreatitis. Intracystic hem-
Received in revised form 26 February 2020 orrhage from a pseudoaneurysm is a rare and potentially a lethal complication of pancreatic pseudocyst with an
Accepted 10 March 2020
incidence of less than 10%. We herein present a case of a 42-year-old male with a past medical history of chronic
Available online xxxx
alcoholic pancreatitis, stable pseudocyst in the tail of pancreas, alcohol abuse and seizures who presented with
Keywords:
abdominal pain and acute anemia had this rare complication of hemorrhagic pseudocyst. The diagnostic modal-
Pseudocyst ities used to diagnose hemorrhagic pseudocyst are ultrasound with color doppler, CT with contrast, digital sub-
Pseudoaneurysm traction angiography and angiography. Angiographic embolization of the culprit artery is the preferred
Angiographic embolization treatment of choice in the treatment of pseudoaneurysms. It is important for early recognition and treatment
of this complication as the mortality can be as high as 40%.
© 2020 Elsevier Inc. All rights reserved.

1. Introduction
Pancreatic pseudocysts are seen both in acute and chronic pancreati-
tis. The prevalence of pancreatic pseudocyst in chronic pancreatitis is 20%
to 40% and is most commonly seen in alcoholic chronic pancreatitis [1].
Complications of pancreatic pseudocyst include compression of abdom-
inal great vessels, gastric outlet or duodenal stenosis, stenosis of common
bile duct, infection and hemorrhage into the cyst [1,2]. We present a case
of a 42-year-old male with a stable pancreatic pseudocyst who presented
with abdominal pain and had a rare complication of hemorrhagic
pseudocyst. Intracystic hemorrhage from a pseudoaneurysm is a rare
and potentially a lethal complication of pancreatic pseudocyst with a
mortality as high as 40%. It is important to consider intracystic hemor-
rhage when a patient with a known pseudocyst presents with abdominal
pain and acute anemia to the Emergency Room as early recognition and
treatment can improve mortality.
2. Case report
A 42-year-old male presented with epigastric abdominal pain for
2 days. The patient also reported nausea and one episode of bloody
⁎ Corresponding author at: 225 Wilkinson Street, Apt 227, Syracuse, NY 13210, United
States of America.
E-mail address: kudaravp@upstate.edu (P. Kudaravalli).
bowel movement 3 days prior to presentation. His past medical history
included chronic alcoholic pancreatitis, stable pseudocyst in the tail of
pancreas, alcohol abuse and seizures. Surgical history included bilateral
foot surgery after a motor vehicle accident. He reported drinking 30
beers a day for several years but did not drink for 2 months prior to pre-
sentation (Fig. 1).
On examination, blood pressure was 149/92 mm Hg and heart rate
was 67 beats/min. Epigastric and left hypochondriac tenderness was
present on exam. Cardiovascular and respiratory system exam was un-
remarkable. Digital rectal exam was positive for dark blood streaks
mixed with stool, no external hemorrhoids were seen and no internal
hemorrhoids were palpable. His laboratory values were significant for
a hemoglobin of 7.7 g/dL and hematocrit of 24.1%, BUN of 11 mg/dL
and creatinine of 0.78 mg/dL. Computed tomography scan of the abdo-
men and pelvis with contrast demonstrated a hyperdense central area
within the mass consistent with intra-cystic hemorrhage from a vascu-
lar erosion. The patient received 2 units of packed red blood cells. Repeat
labs showed a further drop in hemoglobin to 6.4 g/dL and hematocrit of
20.4% even after blood transfusion. The patient underwent an urgent in-
terventional radiology visceral angiogram which showed a large
pseudoaneurysm in the splenic hilum and the aneurysm was success-
fully embolized with packing coils and thrombin injections. The distal
splenic artery was also embolized with a gel foam slurry. There was
no fistula noted between the pseudoaneurysms and the enteral system.
The patient had no further episodes of bloody bowel movements and
improved clinically. A repeat CT angiogram of the abdomen with pre

https://doi.org/10.1016/j.ajem.2020.03.020
0735-6757/© 2020 Elsevier Inc. All rights reserved.

Please cite this article as: P. Kudaravalli, N. Garg, V.S. Pendela, et al., Hemorrhagic pancreatic pseudocyst: A rare complication, American Journal of
Emergency Medicine, https://doi.org/10.1016/j.ajem.2020.03.020
2 P. Kudaravalli et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
Fig. 1. Computed tomography (CT) showed hyperdense central area within the mass
consistent intra-cystic hemorrhage from a vascular erosion.
and post venous and arterial phase to evaluate the spleen was sought
prior to discharge which demonstrated decreased perfusion to the
spleen. Hepatobiliary surgery was consulted who recommended against
splenectomy given the patent gastroduodenal artery. The patient was
administered appropriate vaccinations for functional asplenia and
discharged (Fig. 2).
3. Discussion
Pancreatic pseudocysts are a common complication seen in chronic
pancreatitis, but pancreatic pseudoaneurysms are seen in less than
10% of patients. Intracystic bleeding is a rare but serious life-
threatening complication. The incidence of intracystic hemorrhage as-
sociated with chronic pancreatitis is 6%–17%. Pseudoaneurysms are
also seen after biliopancreatic surgery. Early recognition and manage-
ment of this complication is imperative due to its mortality rate of 40%
[3,4].
The splenic artery is the most commonly involved artery (30–50%)
as it runs along the pancreatic bed, followed by gastroduodenal artery
in 17% and pancreaticoduodenal artery in 11% of cases [5]. It is hypoth-
esized that the pseudoaneurysm is formed due to direct pressure from
the pseudocyst leading to erosion into a visceral artery and
autodigestion of an arterial wall by the proteolytic enzymes in the
pseudocyst or from severe inflammation during an episode of acute
pancreatitis [6]. Fistula formation can occur between the pseudocyst
and a viscus resulting in an upper or lower gastrointestinal bleeding.
Hemorrhagic pseudocyst can also rupture into the retroperitoneum, bil-
iary tract or peritoneum causing retroperitoneal bleeding, hemobilia or
hemosuccus pancreatitis respectively [2].
Bleeding into the pancreatic pseudocyst should be suspected
when there is a sudden drop in the hematocrit without evidence of
Fig. 2. Pseudoaneurysm adjacent to the pancreatic pseudocyst in the tail with a calcified
wall that is status post coiling.
Please cite this article as: P. Kudaravalli, N. Garg, V.S. Pendela, et al., Hemorrhagic pancreatic pseudocyst: A rare complication, American Journal of
Emergency Medicine, https://doi.org/10.1016/j.ajem.2020.03.020
gastrointestinal bleeding in a patient with a known history of
pseudocyst, sudden enlargement of a pseudocyst, presence of a
bruit over the pseudocyst or upper gastrointestinal bleeding with
no evidence of bleed on the esophagogastroduodenoscopy. Patients
with chronic pancreatitis present with recurrent pain and tender-
ness in upper abdomen, anemia, weight loss, upper or lower gastro-
intestinal bleeding and a pulsatile palpable mass in the upper
abdomen [3,5,6].
The diagnostic modalities used are ultrasound with color doppler, CT
with contrast, digital subtraction angiography and angiography. Con-
trast enhanced computed tomography with early and delayed phase
of contrast injection is also used in the diagnosis. Some of the radiolog-
ical findings seen on CT are septa that enhance with contrast injection in
delayed films or a cyst within a cyst appearance. Enhancement is obvi-
ous if the blood flow is high in the feeding artery of the pseudoaneurysm
[7]. The hallmark of diagnosis is a communicating channel seen be-
tween the pseudocyst and the feeding artery seen on duplex doppler ul-
trasound [3].
Angiographic embolization of the culprit artery is the preferred
treatment of choice in the treatment for pseudoaneurysms. Surgery is
not the first choice as the mortality rates can be as high as 20–29% in he-
modynamically unstable patients with a rupture pseudocyst. It is con-
sidered only when patients are unable to undergo or have failed
angiographic embolization and endoscopic management of pseudocyst
is unsuccessful [6,8].
Author contributions
Pujitha Kudaravalli: Writing the abstract, data collection, editing
Nikita Garg: Writing the abstract
Venkata Satish Pendela: Editing and revising the article
Harvir Singh Gambhir: Editing, finalizing and supervision.
Acknowledgements
The case has not been presented before or published before.
Declaration of competing interest
The authors have no conflicts of interests to declare.
Funding
No funding was needed.
Informed patient consent
Informed patient consent was obtained.
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