Progressive growth of a cystic lesion near the pancreatic head

A 56-year-old man was admitted to hospital because of upper abdominal pain and mild fever for 2 weeks. One month previously, the patient had undergone resection of the body and tail of the pancreas and splenectomy for pancreatic malignant tumor, and 2 weeks ago, the patient experienced abdominal pain with mild fever. Enhanced computed tomography (CT) showed a blurred fat space in front of the pancreatic head and swelling of the intestinal wall ([Fig. 1 a]). The symptoms gradually worsened and vomiting occurred a few days before admission. Repeat CT showed a round, low-density mass (diameter 4.6 cm) near the pancreatic head ([Fig. 1 b]). Clinicians considered the diagnosis of pancreatic pseudocyst with infection. Endoscopic ultrasonography (EUS)-guided cyst aspiration was planned.

Fig. 1 Enhanced computed tomography (CT). a A blurred, fat space in front of the pancreatic head was seen, with swelling of the intestinal wall. b Repeat CT showed a round, low-density mass (diameter 4.6 cm) near the pancreatic head.

Endoscopy revealed a large protuberance in the posterior wall of the antrum, several ulcers on the surface ([Fig. 2]), and stenosis of the antrum. EUS showed an elliptical, uneven, hypoechoic mass near the pancreatic head ([Fig. 3 a]), and fluid movement within the mass. Color Doppler ultrasound showed disorder of blood flow within the mass ([Fig. 3 b]), and pulse Doppler ultrasound detected different types of blood flow ([Video 1]). A diagnosis of pseudoaneurysm was confirmed.

Fig. 2 Endoscopy revealed a large protuberance in the posterior wall of the antrum, with several ulcers on the surface.

Fig. 3 Endoscopic ultrasound. a An elliptical, uneven, hypoechoic mass was seen near the pancreatic head, with fluid movement within the mass. b Color Doppler showed disorder of blood flow within the mass.

Video 1 Pseudoaneurysm was diagnosed by endoscopic ultrasonography using color Doppler and pulse Doppler.

The patient underwent emergency surgery. Massive hematemesis occurred after tracheal intubation under general anesthesia. Immediate laparotomy confirmed a pseudoaneurysm of the celiac artery trunk, which had ruptured into the gastric cavity; successful repair was performed.

Pancreatic pseudoaneurysms are rare complications of acute or chronic pancreatitis [1]. Surgery is another cause of pancreatic pseudoaneurysm [2]. The main clinical symptom is abdominal or digestive tract hemorrhage, with a high mortality rate. Contrast-enhanced CT angiography and digital subtraction angiography are the main methods used to diagnose pancreatic pseudoaneurysm [3]. EUS is also an effective method of diagnosis.

Endoscopy_UCTN_Code_CCL_1AZ_2AO

^* These authors contributed equally to this work.

Publication History

Article published online:
22 January 2020

• References

• 1 Pillay WR, Lalloo S, Thomson SR. et al. Embolisation of metachronous pseudoaneurysms complicating chronic pancreatitis. HPB (Oxford) 2003; 5: 251-253
• 2 Lubezky N, Goykhman Y, Nakache R. et al. Early and late presentations of graft arterial pseudoaneurysm following pancreatic transplantation. World J Surg 2013; 37: 1430-1437
• 3 Bartosz Z, Nattakarn L, Marte J. et al. Endovascular management of pancreatitis-related pseudoaneurysms: a review of techniques. Plos One 2018; 13: e0191998