An Incognito Pancreatic Pseudocyst, Atypically Presenting as an Inguinal Hernia
Document Type
Article
Abstract
Introduction: Pancreatic pseudocysts - complications of acute pancreatitis - are typically asymptomatic. We present a pancreatic pseudocyst masquerading as an incarcerated inguinal hernia.
Case Description/Methods: A 37-year-old male with history of alcohol abuse presented to the ER with 2 weeks of worsening left-sided abdominal pain and growing inguinal mass. He was admitted a month ago for acute pancreatitis (BISAP 3) secondary to alcohol use. He had abdominal distention, left-sided dullness to percussion, tenderness, and a reducible inguinal hernia. Lipase and LFTs were normal, but CT abdomen/pelvis showed peripancreatic fluid collection extending into the lesser sac, left hepatic duct, extraperitoneal space of Retzius, and caudally through inguinal canal, measuring 16x9 cm in the lesser sac and 25x16 cm in the paracolic gutter. Scrotal US exhibited omentum and extension of fluid into the left hemiscrotum, otherwise unremarkable. Walled-off necrosis consistent with pancreatic pseudocyst was seen on MRCP. Surgical team deferred hernia repair until pancreatitis resolved. He was treated with conservative management for 3 days and then discharged. Repeat MRCP after 2 months showed pancreatic necrosis and slightly decreased loculated peripancreatic fluid collection compared to prior MR. The GI team was unable to access the fluid endoscopically. IR instead placed a drainage catheter (PCT). He returned to the ER in 2 weeks with fevers, chills, and purulent drainage from the tube, presumed to have infected pseudocyst. The initial drain was deemed incompetent, and IR was asked to reevaluate. The initial drain was exchanged with a larger PCT and 2 additional catheters placed. Over the next 3 days, his symptoms improved with increasing drainage.
Discussion: 48 atypical pseudocyst cases have been reported to date, 10 were inguinal. Cyst on CT (gold standard) with history of pancreatitis is pathognomonic for pancreatic pseudocyst, requiring no other diagnostics. Ultrasound is to further delineate the fluid’s characteristics. Most times MRCP is not needed, but this can help visualize the fluid and pancreatic/biliary ducts. Treatment is indicated for symptomatic cases. Studies show conservative management and PCT drainage are equally effective. Endoscopic drainage or cystostomy can be trialed. Our patient’s initial presentation was concerning for incarcerated hernia, and though ostomy was not feasible due to cyst location and extent, he improved with multiple drains. This case demonstrates a rare pseudocyst presentation.
First Page
S675
DOI
10.14309/01.ajg.0000779436.08147.53
Publication Date
10-1-2021
Recommended Citation
Brahmbhatt A, Pantino K, Duarte-Chavez R, Brahmbhatt M, Sidhu L, Chaput K. S1476 An Incognito Pancreatic Pseudocyst, Atypically Presenting as an Inguinal Hernia. Official journal of the American College of Gastroenterology| ACG. 2021 Oct 1;116:S675.