Case Presentation
A 46-year-old man from North Africa, presented to the emergency department with a complaint of upper abdominal pain and lower back pain for the past 10 days. Moreover, he had been hospitalized five times in the past three years for a condition called hypertriglyceridemia-induced acute pancreatitis.
Doctors inquired about his health problems, including excessive alcohol consumption, and drug abuse, which he denied. Moreover, he did not have any history of surgery or significant family history of illness. He had a poor socio-economic background, thus he was not following the recommended treatment for his hypertriglyceridemia. The patient was also uncooperative and refused to quit smoking.
Examination and Investigations
Upon physical examination, the patient had a vague pain that radiated to his left flank and left upper abdomen. He had a fever but his overall condition was stable. Furthermore, deep palpation of the abdomen caused tenderness.
The patient had an elevated white blood cell count (14.2 × 103/μL), but his haemoglobin levels were within the normal range (13.3 g/dL). The C-reactive protein level was found to be elevated (298 mg/L, normal values < 6 mg/L). Other blood chemistry levels, including serum lipase and amylase, liver function tests, and serum creatinine, were normal. The urine culture did not show any abnormalities.
An abdominal computed tomography (CT) scan performed on the first day of his arrival showed a 40 × 25 mm abscess in his left kidney and a 68 × 50 mm pancreatic pseudocyst in the retroperitoneal area. As a result, doctors admitted the patient to the urology department for the treatment of the renal abscess.
Management
The treatment involved fluid resuscitation and the administration of intravenous cefotaxime and gentamicin as a precautionary measure against possible infections. On the second day, the patient underwent CT-guided percutaneous drainage to remove the fluid from the kidney collection. The fluid obtained during the drainage procedure had an amber colour. Bacteriological and biochemical analysis revealed a high level of amylase (384 UI/L) and tested positive for Escherichia coli, suggesting the presence of an infected pancreatic pseudocyst.
Under the effect of antibiotics, the patient’s fever subsided, and subsequent blood analysis showed a decrease in white blood cell count and C-reactive protein levels after completing a 15-day course of cefotaxime treatment. Doctors performed a follow-up CT scan on the tenth day, which showed a significant reduction in the size of the upper part of the kidney collection, now measuring 20 × 18 mm.
On day 16, he was discharged and transferred to the surgery department. Doctors performed a follow-up ultrasound after 1 month showing total regression of all pseudocysts.
Discussion: Pancreatic Pseudocyst
Pancreatic pseudocysts are a rare and benign condition that can develop in about 10% of cases of acute pancreatitis. They are collections of pancreatic fluid, surrounded by a fibrous capsule without a lining. They can be found inside or outside the pancreas.
There are various factors that contribute to the formation of a pancreatic pseudocyst, such as chronic blockage of the pancreatic duct and leakage of pancreatic enzymes. If left untreated, pancreatic pseudocysts can lead to serious complications like bleeding, infections, or rupture. In this case, the patient had an infected and complicated pseudocyst.
Pancreatic perirenal pseudocysts are usually symptomless and are often discovered incidentally as renal masses. However, in some cases, patients may experience acute complications such as perirenal abscess, obstructive hydronephrosis, pseudoaneurysm, or hypertension caused by renin.
Endoscopic ultrasound (EUS) shows the connection between the main pancreatic duct and the renal pseudocyst in 42% of patients with chronic pancreatitis. In situations where the diagnosis is challenging, doctors drain the fluid from the cyst to be aspirated and analyzed for amylase levels.
Due to the scarcity of cases, there are no specific guidelines for managing perirenal pancreatic pseudocysts. However, with prompt and appropriate treatment, most patients can fully recover. Surgical or percutaneous drainage are possible options, and in some cases, endoscopic transpapillary drainage can be performed with good outcomes.
Conclusion: Pancreatic Pseudocyst
This case is of a 46-year-old patient from North Africa who had a previous episode of acute pancreatitis. Initially, doctors treated the patient in the urology department for an abscess in the left kidney. However, further investigation revealed that it was actually an infected pancreatic pseudocyst located near the left kidney. The patient responded well to percutaneous drainage and received effective antibiotic treatment.
