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Abstracts: CLINICAL VIGNETTES/CASE REPORTS - ENDOSCOPY

Can Small Pancreatic Pseudocyst Cause Significant Gastric Outlet Obstruction?

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Bawany, Muhammad MD; Rafiq, Ehsan MD; Niazi, Muhammad M.D; Thotakura, Raja MD; Nawras, Ali MD, FACG

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American Journal of Gastroenterology: October 2012 - Volume 107 - Issue - p S523
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Purpose: Pancreatic pseudocyst develops in about 10% of chronic pancreatitis patients. Small pancreatic pseudocyst located at or adjacent to the head of pancreas could potentially cause biliary and pancreatic ductal obstruction. On the other hand, Gastric outlet obstruction (GOO) due to external compression caused by the pseudocyst is usually occurs when the cyst is mostly large in size. We report a case of small pseudocyst (1.2 cm in width) with a unique shape and location causing significant GOO that was treated successfully with endoscopy. 52-year-old male was evaluated for epigastric abdominal pain associated with nausea, vomiting and early satiety for few weeks. He denied any diarrhea, weight loss or abdominal distention. His past medical history was significant for chronic pancreatitis. Patient drank alcohol occasionally. On examination, vital signs were normal. Abdominal exam showed mild epigastric tenderness and rest of the examination was unremarkable. His laboratory work was with in normal limits including pancreatic enzymes. CAT scan abdomen showed dilated pancreatic duct and peripancreatic fluid collection (pseudocyst) surrounding the pylorus. EGD and EUS revealed external compression surrounding the pyloric channel and anechoic cystic lesion (measured 1.2 cm in width) encircling the pylorus in 360 degrees (like a donut) causing pyloric stenosis. EUS guided Cystogastrostomy (CTG) was performed with the placement of two double pigtail stent within the stoma site. Pyloric channel became patent as soon as pseudocyst was drained. Patient's symptom improved immediately after the procedure and 4 weeks follow up CAT scan revealed complete resolution of the pseudocyst. The CTG stents were removed 2 weeks later. The patient continued to be asymptomatic in a 6-month follow up. Small pancreatic pseudocyst may cause significant symptomatic gastric outlet obstruction when it has a unique shape and location.

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Figure:
[1320] Top Right: Stenotic Pylorus Top Left: Donut Staped Psuedocyst encircling the Pylorus Bottom: Endoscopic Cystgastrosotomy with double pigtail stents.
© The American College of Gastroenterology 2012. All Rights Reserved.