A Case of Perforated Pancreatic Pseudocyst

Division of Gastroenterology, Changi General Hospital. Singapore, Singapore
ABSTRACT
Context Endoscopic ultrasound guided transmural drainage is a well accepted treatment modality for symptomatic pancreatic
pseudocysts. Pseudocyst perforation is an indication for surgery. The safety and utility of endoscopic drainage in the setting of acute
myocardial infarction is unknown. This report described a case of perforated pseudocyst in a patient with acute myocardial infarction
successfully treated by endoscopic ultrasound guided drainage. Case report An 81-year-old man was admitted for acute myocardial
infarction precipitated by anemia. Computer tomography showed a 17x11 cm pancreatic pseudocyst. Two days later he developed
increased pain and computer tomography showed evidence of pseudocyst perforation. There was further intracystic bleeding that
precipitated a second acute myocardial infarction. There was no peritonism presumably due to the fact that the pseudocyst wall had
resealed temporarily. He was considered too high risk for surgery and hence underwent endoscopic ultrasound guided pseudocyst
drainage. Endoscopic drainage was successful and his symptoms improved. Three weeks later, endoscopic retrograde
pancreatography was performed to evaluate the pancreatic duct integrity; this showed a pancreatic duct fistula communicating with
the pseudocyst cavity, and pancreatic duct stenting was performed. There was complete resolution of both the pseudocyst and
pancreatic duct fistula. Follow-up computer tomography performed 3 months after removal of stents showed no pseudocyst
recurrence. Conclusions In the setting of acute myocardial infarction and contained pseudocyst perforation, endoscopic ultrasound
guided drainage may be performed successfully.
INTRODUCTION
 
Endoscopic ultrasound (EUS)-guided transmural
drainage is a well accepted treatment modality for
symptomatic pancreatic pseudocysts [1]. In the context
of pseudocyst perforation, surgery is frequently
needed. The safety and utility of EUS-guided
pseudocyst drainage in the setting of acute myocardial
infarction is unknown. This report described a case of
perforated pancreatic pseudocyst complicated by acute
myocardial infarction successfully treated by EUS-
guided transgastric drainage.
 
CASE REPORT
 
An 81-year-old Indian male with medical co-
morbidities of ischemic heart disease with previous
coronary bypass, hypertension, hyperlipidemia and
obesity was admitted with symptoms of nausea and
abdominal pain. Serum amylase done on admission
was 312 U/L, less than 3-times elevated (reference
range: 30-162 U/L). The symptoms were attributed to
gastroenteritis and he was discharged a day later when
symptoms resolved. A month later, he was again
hospitalized for one day due to transient abdominal
pain and was discharged well. However, the next day,
he was readmitted to hospital for acute myocardial
infarction precipitated by a decrease in hemoglobin
level from 12.1 to 8.5 g/dL (reference range: 14-18
g/dL). The diagnosis of acute myocardial infarction
was based on presence of angina, ST segment
depression and T wave inversion in the anterolateral
leads of the electrocardiogram, as well as an elevated
troponin T level of 0.123 ng/mL (normal reference: 0-
0.1 ng/mL). There were no overt signs of bleeding such
as hemetemesis or melaena and the abdominal
examination was unremarkable with no tenderness or
masses. He received blood transfusion and the
hemoglobin level rose to 10.4 g/dL. He was on aspirin
and this was stopped and omeprazole was
administered. As there was no evidence of overt
gastrointestinal bleeding that would require immediate
endoscopic therapy, the managing cardiologist deferred
making a referral for diagnostic upper gastrointestinal
Received January 3rd, 2009 - Accepted March 11th, 2009
Key words Anemia; Drainage; Endosonography; Pancreas
Abbreviations CT: computer tomography; EUS: endoscopic
ultrasound
Correspondence Tiing Leong Ang
Division of Gastroenterology, Changi General Hospital, 2 Simei
Street 3, Singapore 529889, Singapore
Phone: +65-685.035.58; Fax: +65-678.162.02
E-mail: tiing_leong_ang@cgh.com.sg
Document URL http://www.joplink.net/prev/200905/03.html

Page 2
JOP. J Pancreas (Online) 2009 May 18; 10(3):324-327.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 3 - May 2009. [ISSN 1590-8577]
325
endoscopy until 9 days later, when it was clear that the
cardiovascular status of the patient would remain
stable. Endoscopy showed only gastritis; there were no
ulcers or cancers that could have accounted for the
drop in hemoglobin level. Concurrently a non urgent
echocardiogram was arranged to assess the left
ventricular function. It showed normal left ventricular
ejection of 60% and an incidental cystic intra-
abdominal lesion. It was only then that computer
tomography (CT) was performed to clarify the nature
of this cystic lesion. CT detected a 17x11 cm
pancreatic pseudocyst (Figure 1). There was intracystic
density consistent with blood. In retrospect, the patient
probably developed an episode of acute pancreatitis a
month earlier, when he first had abdominal pain,
although the serum amylase was less than 3-times
elevated; the etiology of the pancreatitis was gallstone
pancreatitis but there was no sign of biliary obstruction
with normal liver function test and a non dilated bile
duct on CT. The episode of pain prior to the acute
myocardial infarction probably reflected bleeding into
the pseudocyst cavity. Two days later, he developed a
transient episode of severe abdominal pain. The
hemoglobin level dropped to 8.9 g/dL. CT was
repeated and showed that while the pseudocyst
remained largely stable in size and configuration, there
was radiological evidence of perforation at the region
of the left hypochondrium with new inflammatory
changes and fluid collections with high density
consistent with blood. In addition, he suffered another
episode of acute myocardial infarction, as evidenced by
new ST segment depression in the anterolateral leads
of the electrocardiogram as well as an elevation of the
troponin T level to 1.29 ng/mL. He was also transiently
hypotensive requiring inotropic support. He was judged
to be too high risk for surgery, but because of the risk
of frank rupture with peritonitis, which could be
catastrophic and fatal, the option of non surgical
drainage was raised. After discussion, the patient and
his family opted for EUS-guided transmural drainage
which was performed a day after the second episode of
acute myocardial infarction. The patient was sedated
with a combination of intravenous midazolam and
fentanyl. A therapeutic echoendoscope (GF
UCT160TM, Olympus, Tokyo, Japan) was used. The
pseudocyst (Figure 2) was visualized and under
Doppler ultrasound guidance, it was punctured using a
19G needle (EUSN-19-TTM, Cook Endoscopy,
Winston-Salem, NC, USA) via a transgastric approach.
A 0.035” guidewire (Hydra JagwireTM
Guidewire,
Boston Scientific, Natick, MA, USA) was then inserted
through the needle into the pseudocyst cavity and the
needle was withdrawn. The puncture tract was
progressively dilated using a wire-guided needle knife
(KD-441Q, Olympus, Tokyo, Japan) followed by
balloon dilatation (Figure 3) to 8 mm (CRETM, Boston
Scientific, Natick, MA, USA) and a 10 Fr 7 cm double
pigtail stent (SolusTM, Cook Endoscopy, Winston-
Salem, NC, USA) was inserted (Figures 4 and 5). The
patient tolerated the procedure well and no
cardiopulmonary complications developed. Clopidrogel
was started a day later for the treatment of acute
myocardial infarction. His abdominal symptoms
improved and oral feeding was gradually reintroduced.
Figure 1. Computer tomography showing the pancreatic pseudocyst.
Figure 3. Balloon dilatation of the puncture site was performed to
facilitate insertion of a 10 Fr double pigtail transgastric stent.
Figure 2. EUS-guided puncture of the pancreatic pseudocyst.

Page 3
JOP. J Pancreas (Online) 2009 May 18; 10(3):324-327.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 3 - May 2009. [ISSN 1590-8577]
326
A week later CT showed interval regression in the size
of the pseudocyst (13.5 by 5.5 cm). To facilitate faster
resolution, 2 more 10 Fr 7cm transgastric stents were
inserted and he was then discharged. Three weeks later,
endoscopic retrograde pancreatography (ERP) was
performed to evaluate the pancreatic duct integrity. It
showed a pancreatic tail fistula (Figure 6) and this was
treated by insertion of a 7 Fr pancreatic stent. Two
months later CT showed resolution of the pseudocyst
while ERP demonstrated healing of the pancreatic duct
fistula. The transgastric and pancreatic stents were
removed. CT was repeated after a further 3 months and
showed no pseudocyst recurrence.
 
DISCUSSION
 
There are no published data concerning EUS-guided
pseudocyst drainage in the context of a ruptured
pseudocyst in a patient with acute myocardial
infarction. In this case, the patient probably had an
unrecognized episode of acute gallstone pancreatitis
when he first presented with abdominal pain a month
prior to the detection of ruptured pseudocyst. The
perforation was heralded by an episode of intracystic
bleeding that precipitated the first acute myocardial
infarction episode. Subsequently perforation occurred
and triggered another acute myocardial infarction.
Although there was spontaneous sealing at the site of
perforation, as evidenced by the fact that the contours
of the pseudocyst remained largely unchanged, there
was a very real risk of another episode that would
result in frank rupture with peritonitis and death.
As a rule, EUS-guided pseudocyst drainage would
have been regarded as the first treatment option, when
the expertise is available. A review that compared EUS
guided pseudocyst drainage with percutaneous and
surgical alternatives showed that the complication rates
were higher for surgical (28-34%, with 1-8.5%
mortality) and percutaneous drainage (18%, with 2%
mortality), compared to EUS-guided transmural
drainage (1.5%, with 0% mortality) [2]. In the context
of perforation, surgery would have to be considered
very strongly. However, this case was complicated by
two episodes of acute myocardial infarction, and hence
was assessed to be a very high surgical risk. Less
invasive alternatives had to be explored, including
conservative management with no further
interventions, percutaneous drainage and endoscopic
drainage. Given the fact that progressively severe
complications occurred, with initial bleeding followed
by perforation, conservative management alone would
clearly not be possible, since a potentially fatal free
perforation could occur. Percutaneous drainage is at
this point a very viable less invasive option. However,
it does have its inherent risks. It necessitates an
Figure 4. Endoscopic view of a double pigtail transgastric stent.
Figure 5. Radiological view of a double pigtail transgastric stent.
Figure 6. Presence of a communication between the pancreatic duct
and the pseudocyst cavity.

Page 4
JOP. J Pancreas (Online) 2009 May 18; 10(3):324-327.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 3 - May 2009. [ISSN 1590-8577]
327
external indwelling drainage catheter, and
complications such as bleeding, inadvertent puncture of
adjacent viscera, perforation and secondary infection
may occur. A prolonged period of external drainage
may be needed and a pancreatico-cutaneous fistula
could occur [1].
After discussion of the management options the patient
and his family members opted for EUS-guided
endoscopic drainage. This has the advantages of close
proximity and direct access to the pseudocyst cavity
with no need to traverse other organs during the
drainage procedure, the ability to perform drainage
even in the absence of endoscopic bulging, and the
potential to decrease the risk of bleeding by avoiding
interposed blood vessels through the use of Doppler
ultrasound. The problems of cutaneous infection and
external fistulas are also avoided. However, performing
endoscopy in a patient during an active acute
myocardial infarction is fraught with potential risks [3].
The patient is at an increased risk for cardiopulmonary
complications such as arrhythmia, worsening ischemia,
hypotension and respiratory compromise and this has
justifiably resulted in endoscopists being hesitant to
perform endoscopic interventions. Currently there are
no clear guidelines concerning when to perform
endoscopy after an episode of acute myocardial
infarction. It is common to wait for 4 to 6 weeks prior
to performing an elective surgery [4], and this practice
has frequently been adopted into clinical practice for
endoscopy. On the other hand, there are data that
support the utility and safety of therapeutic endoscopy
in patients with acute myocardial infarction, especially
in the context of upper gastrointestinal bleeding [5, 6].
Although frequently endoscopy is delayed to a week, it
has also been safely performed at a shorter time frame.
In a retrospective study that examined endoscopy
performed within a time frame of up to 30 days after
acute myocardial infarction, the overall
cardiopulmonary complication rate was 1.48%. These
complications occurred when endoscopy was
performed within 24 hours of the acute myocardial
infarction (11.8% when considering only endoscopies
performed within 24 hours). On the other hand, no
cardiopulmonary complications were observed during
endoscopy after 24 hours [7].
No doubt this is only a single case report, and one
cannot generalize its applicability to all cases.
However, it does illustrate an important point. Within
the constraints of a narrow therapeutic window, as
illustrated in this case of a patient with contained
perforation and acute myocardial infarction, successful
EUS-guided pseudocyst drainage is possible. This
treatment modality should be borne in mind and could
be offered as a treatment option in selected cases of
contained perforation or in the context of acute
myocardial infarction, with a potential for lower
morbidity in the intermediate and long term when
compared to surgery and percutaneous drainage.
Conflict of interest None
References
1. Seewald S, Ang TL, Kida M, Teng KY, Soehendra N; EUS 2008
Working Group. EUS 2008 Working Group document: evaluation of
EUS-guided drainage of pancreatic-fluid collections (with video).
Gastrointest Endosc 2009; 69(2 Suppl):S13-21. [PMID 19179137]
2. Vosoghi M, Sial S, Garrett B, Feng J, Lee T, Stabile BE,
Eysselein VE. EUS-guided pancreatic pseudocyst drainage: review
and experience at Harbor-UCLA Medical Center. MedGenMed
2002; 4:2. [PMID 12466745]
3. Yazawa K, Adachi W, Koide N, Watanabe H, Koike S,
Hanazaki K. Changes in cardiopulmonary parameters during upper
gastrointestinal endoscopy in patients with heart disease: towards
safer endoscopy. Endoscopy 2000; 32:287-93. [PMID 10774967]
4. Goldman L, Caldera DL, Nussbaum SR, Southwick FS,
Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in
noncardiac surgical procedures. N Engl J Med 1977; 297:845-50.
[PMID 904659]
5. Yachimski P, Hur C. Upper endoscopy in patients with acute
myocardial infarction and upper gastrointestinal bleeding: results of a
decision analysis. Dig Dis Sci 2009; 54:701-11. [PMID 18661236]
6. Mumtaz K, Wasim F, Jafri W, Abid S, Hamid S, Shah H,
Dhakam S. Safety and utility of oesophago-gastro-duodenoscopy in
acute myocardial infarction. Eur J Gastroenterol Hepatol 2008;
20:51-5. [PMID 18090991]
7. Spier BJ, Said A, Moncher K, Pfau PR. Safety of endoscopy
after myocardial infarction based on cardiovascular risk categories: a
retrospective analysis of 135 patients at a tertiary referral medical
center. J Clin Gastroenterol 2007; 41:462-7. [PMID 17450027]

There are no products listed under this category.